AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

AETNA PPO PLAN
SUMMARY PLAN DESCRIPTION
EFFECTIVE JANUARY 1, 2011

CONTENTS
Purpose..................................................................................................................................... 1
Highlights ................................................................................................................................. 1
Terms You Should Know ........................................................................................................ 2
Eligibility ................................................................................................................................. 12
Eligible Associates ............................................................................................................. 12
Eligible Dependents ........................................................................................................... 12
Continuation of Coverage for Ill Students: Michelle’s Law ................................................. 13
Qualified Medical Child Support Orders............................................................................. 13
Who’s Not Eligible.............................................................................................................. 13
Participation ........................................................................................................................... 14
When Participation Begins................................................................................................. 14
Making Benefit Elections.................................................................................................... 15
Special Enrollment Periods................................................................................................ 15
Change in Status................................................................................................................ 16
Enrolling After You Waive Participation ............................................................................. 18
Leaves of Absence............................................................................................................. 18
Rehired Associates ............................................................................................................ 18
When Coverage Ends........................................................................................................ 18
Coordination of Benefits .......................................................................................................20
Coordinating With Another Employer’s Plan...................................................................... 20
Guidelines to Determine Which Plan is Primary and Secondary ....................................... 20
Coordination with Medicare................................................................................................ 21
Updating COB Information – Your Responsibility .............................................................. 22
Specific Information About Your COB................................................................................ 23
Filing COB Claims to Your Secondary Carrier ................................................................... 23
No-Fault Auto Coverage .................................................................................................... 23
Submitting Coordinated Claims.......................................................................................... 23
Continuation of Group Health Coverage ............................................................................ 24
Qualifying Events ............................................................................................................... 24
Election of Coverage.......................................................................................................... 25
Requirements for All Notices.............................................................................................. 25
Cost of Continuation of Coverage ...................................................................................... 26
Termination of Continuation of Coverage .......................................................................... 26
Trade Act of 1974............................................................................................................... 26
USERRA Continuation Coverage ...................................................................................... 27
If You Have Questions ....................................................................................................... 27
Keep the Plan Informed of Address Changes.................................................................... 27
Plan Administration Information .......................................................................................... 28
Employment Rights............................................................................................................ 28
No Warranty of Health Care Providers............................................................................... 28
Designation of Fiduciary Responsibility ............................................................................. 28
Health Insurance Portability and Accountability Act of 1996 (HIPAA)................................ 28
Newborns’ and Mothers’ Health Protection Act of 1996..................................................... 30

Women’s Health and Cancer Rights Act of 1998............................................................... 30
Plan Administrator Powers................................................................................................. 31
Filing a Claim for Benefits and Review Procedures ........................................................... 31
How to Submit a Claim for Benefits ................................................................................... 31
Reporting of Claims............................................................................................................32
Claims, Appeals and External Review ............................................................................... 32
Filing Health Claims Under the Plan ............................................................................ 32
Other Claims ................................................................................................................ 32
Health Claims: Standard Appeals ................................................................................ 33
Exhaustion of Internal Appeals Process ...................................................................... 33
Full and Fair Review of Claim Determinations and Appeals ........................................ 33
Health Claims: Voluntary Appeals...................................................................................... 34
External Review ........................................................................................................... 34
Request for External Review........................................................................................ 35
Preliminary Review ...................................................................................................... 35
Referral to ERO............................................................................................................ 36
Expedited External Review .......................................................................................... 36
Referral of Expedited Review to ERO.......................................................................... 37
Legal Action ....................................................................................................................... 37
Subrogation and Right of Reimbursement ......................................................................... 37
Amendment or Termination of the Plan ............................................................................. 39
State of Michigan Disclosure Requirement ........................................................................ 40
Employee Retirement Income Security Act of 1974 (ERISA)
Statement of Participant Rights ........................................................................................ 41
Important Information About the Plan ................................................................................. 43
How Services Are Paid Through the Plan ........................................................................... 44
Covered Medical Expenses................................................................................................... 45
How Will You Benefit From Choosing a Network Provider? .............................................. 45
What Happens If You Are Not Able to Use a Network Provider?....................................... 45
What Is The Plan Deductible?............................................................................................ 46
What Is Your Out-of-Pocket Maximum Expense?.............................................................. 46
Health Management Services............................................................................................ 46
Case Management............................................................................................................. 47
Pre-Certification of Services............................................................................................... 47
Mental Disorders and/or Substance Abuse........................................................................ 48
Explanation of Some Important Plan Provisions ................................................................ 48
Genetic Testing/Screening and Counseling....................................................................... 49
Hospital Expenses ............................................................................................................. 50
Inpatient Hospital Expenses......................................................................................... 50
Outpatient Hospital Expenses...................................................................................... 50
Outpatient Surgical Expenses...................................................................................... 51
Outpatient Services and Supplies ................................................................................ 51
Convalescent Facility Expenses ........................................................................................ 51
Home Health Care Expenses............................................................................................. 52
Preventive Physical Exam Expenses................................................................................. 53

Preventive Hearing Exam Expenses.................................................................................. 54
Hospice Care Expenses..................................................................................................... 55
Outpatient Short-Term Rehabilitation Expense Coverage ................................................. 56
Prescription Drugs.............................................................................................................. 57
Filing Claims................................................................................................................. 60
Claims Appeal Procedures........................................................................................... 61
External Review ........................................................................................................... 62
Non-Surgical Weight Loss Programs/Smoking Cessation ................................................. 62
Spinal Disorder Treatment Benefit ..................................................................................... 63
Other Medical Expenses.................................................................................................... 63
Complex Imaging Services ................................................................................................ 64
National Medical Excellence Program (NME) .................................................................... 64
Travel Expenses .......................................................................................................... 64
Lodging Expenses........................................................................................................ 64
Travel and Lodging Benefit Maximum.......................................................................... 65
Limitations ....................................................................................................................65
Weight Management.......................................................................................................... 65
Limitations.......................................................................................................................... 66
Preventive Mammogram .............................................................................................. 66
Preventive Screening for Cancer ................................................................................. 66
Mouth, Jaws and Teeth................................................................................................ 66
Emergency Room Treatment ....................................................................................... 68
Treatment By An Urgent Care Provider ....................................................................... 68
Treatment of Alcoholism, Drug Abuse, or Mental Disorders ........................................ 69
General Exclusions................................................................................................................ 70

PURPOSE
This document, along with other referenced documents (e.g., Benefits Summary, etc.), constitutes the
Summary Plan Description for the health care coverage under the Medical Program component of Plan
504 of the Trinity Health Welfare Benefit Plan that is provided through the Aetna Life Insurance Company
(“Aetna”) Preferred Provider Organization (“PPO”) Health Care Plan (“Plan”). This Summary Plan
Description (“SPD”) is intended to provide you with an overview of important information about the Plan.
Coverage through this Plan is offered to benefits-eligible Associates of Trinity Health (“Trinity Health”) and
the Trinity Health Ministry Organizations that have adopted the Plan and their eligible Dependents.
This SPD may be an electronic version of the SPD on file with Trinity Health and Aetna. In case of any
discrepancy between an electronic version of this SPD and the printed version on file with Trinity Health,
the terms set forth in the printed version on file with Trinity Health will prevail. In addition, in case of any
discrepancy between the SPD (electronic or printed) and the actual Plan document, the Plan document
will prevail. To obtain a printed copy of this SPD and/or the Plan document, please contact the Plan
Administrator.
HIGHLIGHTS
This SPD features:
• Terms you should know
• Eligibility and participation rules
• An explanation of how your medical benefits may coordinate with other medical coverage
• Details about continuing group health coverage
• An understanding of the administration of the Plan
• An overview of your rights required by federal law
• Contact information
• Highlights of your medical and Prescription Drug coverage
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TERMS YOU SHOULD KNOW
It is important that you understand how the Plan works and your rights as a Covered Individual. Important
terms are defined below. These defined terms will be capitalized throughout the document for your
convenience. Any references to “you” or “your” in this SPD are references to the eligible Associate unless
the context clearly indicates otherwise.
AETNA
A leading Provider of health care, dental, pharmacy, life, and disability insurance dedicated to helping
people achieve health and financial security by providing easy access to safe, cost-effective, high-quality
health care and protecting their finances against health-related risks.
ALLOGENEIC (ALLOGENIC) TRANSPLANT
A procedure using another person’s bone marrow or peripheral blood stem cells to transplant into the
patient (including syngeneic transplants, when the donor is the identical twin of the patient).
ANNUAL OPEN ENROLLMENT
Annual Open Enrollment is the period of time each year when you may enroll yourself and your eligible
Dependents for coverage, make applicable changes to your existing coverage, and terminate coverage,
effective as of the first day of the next Plan Year.
ASSOCIATE
A person who is employed by an Employer as a common law employee.
AUTHORIZED REPRESENTATIVE
A Physician rendering the service for which a bill is submitted, (but not a designee of the Physician) or a
person who a Covered Individual has authorized in writing to act on his or her behalf. If a claim is an urgent
care pre-service claim, the Plan will consider a Health Care Professional with knowledge of a claimant’s
medical condition as an Authorized Representative.
If a Covered Individual wishes to authorize another person (e.g., family member) to act on his or her behalf
on matters that relate to filing of benefit claims, notification of benefit determinations, and/or appeal of benefit
denials, he or she must first notify the Plan Administrator of such authorization by providing a completed
Notice of Authorized Representative form. The Notice of Authorized Representative form can be obtained
from your Employer or the Plan Administrator. The Plan Administrator or its delegate will also recognize a
court order giving a person authority to act on a Covered Individual’s behalf
AUTOLOGOUS TRANSPLANT
A procedure using the patient’s own bone marrow or peripheral blood stem cells for transplantation back
into the patient.
BEHAVIORAL HEALTH PROVIDER
A licensed organization or professional providing diagnostic, therapeutic or psychological services for
behavioral health conditions.
CLAIMS ADMINISTRATOR
An entity that reviews and determines whether to pay claims under the Plan. The Plan has different
Claims Administrators based on the type of claim. The Claims Administrator for each type of claim is
responsible for claim processing within the time periods listed for initial claims determination as well as for the
final decision for any appeal filed in response to an adverse benefit determination. Each is independently
responsible for notifying you of the adverse benefit determination, based on the type of claim, as well as
reviewing any appeal you may make.
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COBRA
Continuation coverage as required by the Consolidated Omnibus Reconciliation Act of 1985
COINSURANCE
A Covered Individual pays a percentage of his or her expenses after his or her Deductible is met. The
portion that a Covered Individual pays is called Coinsurance. The Plan pays the remaining percentage.
COMPANION
This is the person whose presence as a Companion or caregiver is necessary to enable an NME patient who
receives services in connection with an NME procedure or treatment on an Inpatient or out of patient basis; or
who travels to and from the facility where treatment is given.
CONVALESCENT FACILITY
This is an institution that is licensed to provide, and does provide, the following on an Inpatient basis for
persons convalescing from disease or Injury: professional nursing care by a R.N., or by a L.P.N directed by a
full time R.N.; and physical restoration services to help patients to meet a goal of self-care in daily living
activities. It provides 24 hour a day nursing care by licensed nurses directed by a full-time R.N. and is
supervised full-time by a Physician or R.N. This institution keeps a complete medical record on each patient,
has a utilization review plan and makes charges. It is not mainly a place for rest, for the aged, for drugs
addicts, for alcoholics, for metal retardates, for custodial or educational care, or for care of Mental Disorders.
COPAYMENT (OR COPAY)
A Copayment is a cost-sharing arrangement in which a Covered Individual pays a fixed amount for a
specific service. For example, when a Covered Individual has a Physician’s office visit, the Covered
Individual will pay a flat dollar fee for the visit. The Plan pays the remaining expenses.
COVERED EXPENSE
A Covered Expense is the reasonable fee for a Covered Service. Some Covered Expenses are subject to
certain limitations.
COVERED INDIVIDUAL
An eligible Associate or eligible Dependent who is enrolled in the Plan.
COVERED SERVICES
Services, treatments or supplies identified as payable under the Plan. Covered Services must be
Medically Necessary to be payable, unless otherwise specified.
CUSTODIAL CARE
This means services and supplies furnished to a person mainly to help him or her in the activities of daily life.
This includes room and board and other institutional care. The person does not have to be disabled. Such
services and supplies are Custodial Care without regard to by whom they are prescribed or recommended
and by whom or by which they are performed.
DEDUCTIBLE
A Deductible is the amount a Covered Individual pays each Plan Year before the Plan starts to pay its
portion of the Covered Individual’s expenses. The Plan includes one Deductible for Covered Expenses.
There’s no deductible required for prescription drugs.
The deductible is satisfied on a calendar year basis with expenses from January through December. Any
expense applied toward the deductible during the last three months of the calendar year may be applied
towards the deductible for the following year.
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When an individual’s coverage becomes effective during a calendar year, the Deductible will apply only to
expenses that are incurred after the coverage effective date. Network Copayments and Prescription Drug
Copayments cannot be used to satisfy the Plan’s calendar year Deductible. Expenses applied toward the
non-Network Deductible will be used to satisfy the Network deductible, and expenses applied to the Network
Deductible will be applied to the non-Network Deductible.
DENTIST
This means a legally qualified Dentist. Also, a Physician who is licensed to do the dental work he or she
performs.
DEPENDENT
Dependents include your eligible spouse and eligible child(ren) as set forth in the Eligibility section of this
SPD.
EFFECTIVE TREATMENT OF ALCOHOLISM OR DRUG ABUSE
This means a program of alcoholism or drug abuse therapy that is prescribed and supervised by a Physician
and either has a follow-up therapy program directed by a Physician on at least a monthly basis; or includes
meeting at least twice a month with an organization devoted to the treatment of alcoholism or drug abuse.
Not effective treatments are Detoxification, which means mainly treating the aftereffects of a specific episode
of alcoholism or drug abuse; and Maintenance care, which means providing an environment free of alcohol or
drugs.
EFFECTIVE TREATMENT OF A MENTAL DISORDER
This is a program that is prescribed and supervised by a Physician; and is for a disorder that can be favorably
changed.
EMERGENCY
An Emergency is a sudden, serious, and unexpected onset of a medical condition, having symptoms so
acute and of such severity as to require immediate medical attention to prevent permanent danger to
one’s health or other serious medical results, impairment to bodily function or permanent lack of function
of bodily organs or appendages. An Emergency may or may not require Hospital admission, and
treatment must be approved by a Physician or surgeon.
EMERGENCY CARE
This means the treatment given in a Hospital’s emergency room to evaluate and treat medical conditions of a
recent onset and severity, including, but not limited to, severe pain, which would lead a prudent layperson
possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or
Injury is such a nature that failure to get immediate medical care could result in placing the person’s health in
serious jeopardy; or serious impairment to bodily function; or serious dysfunction to bodily part or organ; or in
the case of a pregnant women, serious jeopardy to the health of the fetus.
EMPLOYER
The Employer is Trinity Health and, where applicable and appropriate, the Trinity Health Ministry
Organizations that have adopted the Plan.
EXPERIMENTAL OR INVESTIGATIVE
A service, procedure, treatment, device or supply that has not been scientifically demonstrated to be safe
and effective for treatment of the patient’s condition. Aetna makes this determination based on a review of
established criteria such as:
• Opinions of local and national medical societies, organizations, committees or governmental bodies;
• Accepted national standards of practice in the medical profession;
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• Scientific data such as controlled studies in peer review journals or literature; and
• Opinions of the Blue Cross and Blue Shield Association (“BCBSA”) or other local or national bodies.
The BCBSA is an Association of independent Blue Cross Blue Shield Plans that licenses individual plans
to offer health benefits under the Blue Cross Blue Shield name and logo. The association establishes
uniform financial standards but does not guarantee an individual plan's financial obligations.
GENETIC COUNSELOR
Health Care Professional with specialized graduate degrees and experience in medical genetics and
counseling. It is the Genetic Counselor’s role to provide information to the individual or family regarding the
Genetic Disorder.
GENETIC DISORDER
A disease caused in whole or in part by a variation or mutation of a gene. Genetic disorders can be passed
on to family members who inherit the genetic abnormally.
HEALTH CARE PROFESSIONAL
A Physician or other Health Care Professional licensed, accredited, or certified to perform specific health
services consistent with state law.
HOME HEALTH CARE
A Home Health Care Plan is a plan for the care and treatment of a Covered Individual in his or her home.
To qualify, the plan must be established and approved in writing by a Physician who certifies that the
Covered Individual would require confinement in a Hospital or skilled nursing facility if he or she did not
have the care or treatment stated in the plan.
HOME HEALTH CARE AGENCY
This is an agency that mainly provides nursing and other therapeutic services; and is associated with a
professional group which makes policy; this group must have at least one Physician and one R.N. It has fulltime
supervision by a Physician or a R.N. and full-time administrator. This agency keeps complete medical
records on each person and meets licensing standards.
HOSPICE CARE
Hospice Care is a plan, in writing, by the attending Physician for home or Inpatient Hospice Care that
treats the special needs of a terminally ill person and his or her family.
HOSPICE CARE AGENCY
This is an agency or organization which has Hospice Care available 24 hours a day and meets any incensing
or certification standards set forth by the jurisdiction where it provides skilled nursing and medical social
services; and psychological and dietary counseling. Also provides or arranges for other services which will
include: services of a Physician; physical and occupational therapy; part-time home health aide services
which mainly consist of caring for terminally ill persons; and Inpatient care in a facility when needed for pain
control and acute and chronic symptom management. This agency has personnel which include at least one
Physician, one R.N. and one licensed or certified social worker employed by the Agency. It establishes
policies governing the provision of Hospice Care and assesses the patient’s medical and social needs. The
Hospice Care Agency develops a Hospice Care program to meet those needs and provides an ongoing
quality assurance program. This includes reviews by Physicians, other than those who own or direct the
Agency. This Agency permits all area medical personnel to utilize its services for their patients and keeps a
medical record on each patient. It utilizes volunteers that are trained in providing services for non-medical
needs and has a full-time administrator.
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HOSPICE FACILITY
This is a facility or distinct part of one, which mainly provides Inpatient Hospice Care to terminally ill persons
and provides an ongoing quality assurance program; this includes reviews by Physicians other than those
who own or direct the facility. This facility keeps a medical record on each patient, charges its patients, and
meets any licensing or certification standards set forth by the jurisdiction where it is. This facility is run by a
staff of Physicians; at least one such Physician must be on call at all times and a full-time administrator. This
facility provides 24 hour a day, nursing services under the direction of a R.N.
HOSPITAL
A Hospital is a public or private facility that is licensed to operate according to specific legal requirements.
It must provide care and treatment by Physicians and nurses for an Illness or Injury using medical,
surgical and diagnostic facilities on its premises. A Hospital can also include tuberculosis facilities,
psychiatric facilities and Substance Abuse treatment facilities that are licensed to operate according to
specific legal requirements.
ILLNESS
Illness is a sickness or disease that requires treatment by a Physician. Illness in this summary plan
description includes mental illness and pregnancy.
INJURY
A sudden, unexpected and unforeseen bodily harm that occurs solely through external bodily contact.
(Strains and spasms are considered an Illness rather than an Injury.)
INPATIENT
Services are considered Inpatient if they are provided while a Covered Individual receives treatment in a
Hospital or other health care facility and incurs room and board charges.
L.P.N.
This means a licensed practical nurse.
LATE ENROLLEE
This is an Associate in an Eligible Class who requests enrollment under this Plan after the Initial Enrollment
Period. In addition, this is an eligible Dependent for whom the Associate did not elect coverage within the
Initial Enrollment Period, but for whom coverage is elected at a later time.
However, an eligible Associate or Dependent may not be considered a Late Enrollee under certain
circumstances. See the Special Enrollment Periods section.
MEDICALLY NECESSARY
All Covered Services under the Plan are subject to the requirement of being Medically Necessary and
subject to uniform standards of medical practice. This means:
• The service is for the treatment or diagnosis of symptoms of an Injury, Illness, condition or disease;
• The service is consistent with the diagnosis and is appropriate for the symptoms;
• The type, level and length of care, the treatment or medical supply, and the setting are needed to
provide safe and adequate care;
• The service is commonly and usually noted throughout the medical field as proper to treat or
diagnose the condition, disease, Injury or Illness; and
• The care is not Experimental or Investigational as determined by the Plan’s Claims Administrator (see
page four for further details).
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A service or supply is not Medically Necessary if made, prescribed, or delivered mainly for the
convenience of the patient or Provider. The fact that a Physician has prescribed a procedure or treatment
does not mean that it is Medically Necessary.
MENTAL DISORDER
This is a disease commonly understood to be a Mental Disorder whether or not it has a physiological or
organic basis and for which treatment is generally provided by or under the direction of a mental health
professional such as a psychiatrist, a psychologist or a psychiatric social worker. A Mental Disorder includes;
but is not limited to: alcoholism and drug abuse, schizophrenia, bipolar disorder, Pervasive Mental
Development Disorder (Autism), panic disorder, major depressive disorder, psychotic depression, obsessive
compulsive disorder. For the purpose of benefits under this Plan, metal disorder will include alcoholism and
drug abuse only if any separate benefit for a particular type of treatment does not apply to alcoholism and
drug abuse.
MORBID OBESITY
This means a Body Mass Index that is; greater than 40 kilograms per meter squared; or equal to or greater
than 35 kilograms per meter squared with a comorbid medical condition, including: hypertension; a
cardiopulmonary condition; sleep apnea; or diabetes.
NEGOTIATED CHARGE
This is the maximum charge a Preferred Care has agreed to make as to any service or supply for the
purpose of the benefits under this Plan.
NETWORK
A Network is a group of Physicians, Hospitals, pharmacies, and other health care Providers that have
agreed to provide health care services subject to negotiated fee arrangements.
ORTHODONTIC TREATMENT
This is any medical service or supply; or dental service or supply; furnished to prevent or to diagnose or to
correct a misalignment of the teeth, bite, jaws or jaw joint relationship; whether or not for the purpose of
relieving pain. It does not include the installation of a space maintainer or a surgical procedure to correct
malocclusion.
OUT-OF-POCKET MAXIMUM
The Out-of-Pocket Maximum is the most a Covered Individual will pay for Covered Expenses during a
Plan Year.
OUTPATIENT
Services are considered Outpatient if they are provided while a Covered Individual receives treatment
either outside a Hospital or other health care Provider or in a Hospital or other health care Provider but
the Covered Individual does not incur room and board charges.
PHYSICIAN
A Physician is a doctor of medicine (M.D.) or osteopathy (D.O.) legally qualified and licensed to practice
medicine or osteopathic medicine and/or perform Surgery at the time and place a service is rendered or
performed. The term Physician may also include categories of limited practice professionals who are
legally qualified and licensed as specified elsewhere in this document.
PLAN
The Plan is the health care coverage under the Medical Program component of Plan 504 of the Trinity
Health Welfare Benefit Plan that is provided through the Aetna Life Insurance Company (“Aetna”)
Preferred Provider Organization (“PPO”) Health Care Plan.
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PLAN ADMINISTRATOR
Trinity Health
PLAN YEAR
The Plan Year is the 12-month period beginning on January 1 and ending on the following December 31.
You have the opportunity to change your medical coverage during the Annual Open Enrollment period
before the new Plan Year begins.
PREFERRED CARE
This is a health care service or supply furnished by a person’s Primary Care Physician or any other Preferred
Care Provider. Also furnished by a person’s Primary Care Physician prior to treatment and a Non-Preferred
Urgent Care Provider when travel to a Preferred Urgent Care Provider for treatment is not feasible. Preferred
Care is also care, which is recommended and approved by the BHCC.
PREFERRED CARE PROVIDER
This is a health care provider that has contracted to furnish services or supplies for a Negotiated Charge; but
only if the provider is, with Aetna’s consent, including in the directory as a Preferred Care Provider for the
service or supply involved; and the class of associates of which you are member.
PRESCRIPTION DRUG
Those drugs approved by the Food and Drug Administration of the United States which require a written
prescription by a Physician or Dentist and which bear the legend, “Caution: Federal law prohibits
dispensing without a prescription.”
PRIMARY CARE PHYSICIAN
This is the Preferred Care Provider who is selected by a person from the list of Primary Care Physicians in
the directory, is responsible for the person’s on-going health care; and is shown on Aetna’s records as the
person’s Primary Care Physicians.
PROVIDER
A person (such as a Physician) or a facility (such as a Hospital) that provides services or supplies related
to medical care.
• Trinity Health Facilities – Trinity Health’s facilities, its Ministry Organization’s Hospitals and satellite
locations.
• Network Providers – Hospitals, Physicians and other licensed facilities or Health Care Professionals
who have contracted with Aetna to provide services to members enrolled in a PPO health care Plan.
Network Providers have agreed to accept Aetna’s approved amount as payment in full for Covered
Services.
• Nonparticipating (Out-of-Network) Providers — Providers who are not part of the Aetna PPO
provider Network. Out-of-Network Providers have not signed participation agreements with Aetna
agreeing to accept the Aetna payment as payment in full. However, nonparticipating Providers may
agree to accept the Aetna approved amount as payment in full on a per claim basis. However,
because these Providers are not a part of the PPO Network, you must pay higher out-of-pocket costs.
R.N.
This means a registered nurse.
REASONABLE CHARGE
The Reasonable Charge for a service or supply is the lowest of the Provider’s usual charge for furnishing it;
and the charge Aetna determines to be appropriate, based on factors such as the cost of providing the same
or a similar service or supply and the manner in which charges for the service or supply are made; and the
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charge Aetna determines to be the prevailing charge level made for it in the geographic area where it is
furnished. In determining the Reasonable Charge for a service or supply that is unusual, not often provided in
the area or provided by only a small number of Providers in the area. Aetna may take into account factors,
such as the complexity, degree of skill needed, type of specialty of the Provider, range of services or supplies
provided by a facility, and prevailing charge in other areas. In some circumstances, Aetna may have an
agreement with a Provider (either directly, or indirectly through a third party), which sets the rate that Aetna
will pay for a service or supply. In these instances, in spite of the methodology described above, the
Reasonable Charge is the rate established in such agreement.
RESIDENTIAL TREATMENT FACILITY – ALCOHOLISM AND DRUG ABUSE
This is an institution that meets all of the following requirements:
• On-site licensed Behavioral Health Provider 24 hours per day/seven days a week
• Provides a comprehensive patient assessment (preferably before admission, but at least upon
admission)
• Is admitted by a Physician
• Has access to necessary medical services 24 hours per day/seven days a week
• If the member requires detoxification services, must have the availability of on-site medical treatment 24
hours per day/seven days a week, which must be actively supervised by an attending Physician
• Provides living arrangements that foster community living and peer interaction that are consistent with
developmental needs
• Offers group therapy sessions with at least an RN or Masters-Level Health Professional
• Has the ability to involve family/support systems in therapy (required for children and adolescents;
encouraged for adults)
• Provides access to at least weekly sessions with a Psychiatrist or psychologist for individual
psychotherapy
• Has peer oriented activities
• Services are managed by a licensed Behavioral Health Provider who, while not needing to be individually
contracted, needs to (1) meet the Aetna credentialing criteria as an individual practitioner, and (2)
function under the direction/supervision of a licensed psychiatrist (Medical Director)
• Has individual active treatment plan directed toward the alleviation of the impairment that caused the
admission
• Provides a level of skilled intervention consistent with patient risk
• Meets any and all applicable licensing standards established by the jurisdiction in which it is located
• Is not a Wilderness Treatment Program or any such related or similar program, school and/or education
service
• Ability to assess and recognize withdrawal complications that threaten life or bodily functions and to
obtain needed services either on site or externally
• 24-hours per day/seven days a week supervision by a Physician with evidence of close and frequent
observation
• On-site, licensed Behavioral Health Provider, medical or substance abuse professionals 24 hours per
day/seven days a week
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RESIDENTIAL TREATMENT FACILITY – MENTAL DISORDERS
This is an institution that meets all of the following requirements:
• On-site licensed Behavioral Health Provider 24 hours per day/seven days a week
• Provides a comprehensive patient assessment (preferably before admission, but at least upon
admission)
• Is admitted by a Physician
• Has access to necessary medical services 24 hours per day/seven days a week
• Provides living arrangements that foster community living and peer interaction that are consistent with
developmental needs
• Offers group therapy session with at least an RN or Masters-Level Health Professional
• Has the ability to involve family/support systems in therapy (required for children and adolescents;
encouraged for adults)
• Provides access to at least weekly sessions with a Psychiatrist or psychologist for individual
psychotherapy
• Has peer oriented activities
• Services are managed by a licensed Behavior Health Provider who, while not needing to be individually
contracted, needs to (1) meet the Aetna credentialing criteria as an individual practitioner, and (2)
function under the direction/supervision of a licensed psychiatrist (medial Director)
• Has individualized active treatment plan directed toward the alleviation of the impairment that caused the
admission
• Provides a level of skilled intervention consistent with patient risk
• Meets any and all applicable licensing standards established by the jurisdiction in which it is located
• Is not a Wilderness Treatment Program or any such related or similar program, school and/or education
service
SURGERY
A cutting operation, suturing of a wound, treatment of a fracture, relocation of dislocation, radiotherapy (if
used in lieu of a cutting operation) diagnostic and therapeutic endoscopic procedures, laser surgery, and
injections classified a Surgery under the CPT.
URGENT CARE PROVIDER
This is a freestanding medical facility which provides unscheduled medical services to treat an Urgent
Condition if the person’s Physician is not reasonable available, routinely provides ongoing unscheduled
medical services for more than eight consecutive hours and makes charges. They are licensed and certified
as required by any state or federal law or regulation. They keep a medical record on each patient. Urgent
Care Provider provides an ongoing quality assurance program, which includes reviews by Physicians other
than those who own or direct the facility. Its run by a staff of Physicians, at least on Physician must be on call
at all times and has a full-time administrator who is licensed Physician. Similar to a Physician’s office, but only
one that has contracted with Aetna to provide urgent care; and is with Aetna’s consent, included in the
directory as Preferred Urgent Care Provider. It is not the emergency room or Outpatient department of a
hospital.
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URGENT CONDITION
This means a sudden Illness; Injury; or condition; that is severe enough to require prompt medical attention to
avoid serious deterioration of the covered person’s health; includes a condition which would subject the
covered person to severe pain that could not be adequately managed without urgent care or treatment; does
not require the level of care provided in the emergency room of a hospital; and requires immediate Outpatient
medical care that cannot be postponed until the covered person’s Physician becomes reasonably available.
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ELIGIBILITY
ELIGIBLE ASSOCIATES
You are eligible to participate in the Plan if you are a benefits-eligible Associate, as defined in your
Employer’s policy that defines Associate classifications. Please contact your Employer for a copy of its
policy that defines Associate classifications.
ELIGIBLE DEPENDENTS
Your spouse is eligible for coverage under the Plan provided he or she meets both of the following
criteria:
1) The person is legally married to you under applicable State and Federal law and the IRS recognizes
the person as your spouse for income tax purposes. A person who is your spouse as a result of a
common law marriage is not eligible for coverage under the Plan.
2) The person is not otherwise covered under the Plan or any other group health plan offered by the
Employer.
Your children are eligible for coverage under the Plan through the end of the Plan Year in which they turn
age 26, regardless of marital status, student status, residency, financial dependency or other
requirements provided they meet both of the following criteria:
1) They are:
• Your natural children;
• Your legally adopted children or children placed with you for adoption;
• Your stepchildren (i.e., the natural or legally adopted children of your legal spouse (as defined
above)); or
• Children for whom you or your legal spouse are the court-appointed legal guardian.
2) They are not otherwise covered under the Plan or any other group health plan offered by the
Employer.
In addition, the children listed above are eligible for coverage under the Plan after they turn age 26 if they
meet all of the following criteria:
1) They are totally and permanently Disabled and become Disabled prior to their 26 th birthday.
2) They are unmarried.
3) They are not otherwise covered under the Plan or any other group health plan offered by the Employer.
4) They are continuously enrolled in a creditable plan prior to their 26 th birthday.
5) They either:
a) Live in the same house as you for more than half of the year and do not provide more than half of
their own support for the year; or
b) Are not anyone’s “qualifying children” for the year (as defined in Internal Revenue Code Section
152(c)) and you provide over half of their support for the year.
To view the complete eligibility rules and documentation requirements for you and your family members,
visit http://mybenefits.trinity-health.org.
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CONTINUATION OF COVERAGE FOR ILL STUDENTS: MICHELLE’S LAW
Effective January 1, 2010, the Employee Retirement Income Security Act of 1974 (ERISA) includes
Michelle’s Law. To the extent Michelle’s Law is still applicable after the enactment of the Patient
Protection and Affordable Care Act (PPACA) and its implementing regulations, the Plan will not terminate
your covered Dependent child’s coverage if he or she cannot maintain a full-time course load due to a
Medically Necessary leave of absence from school (or a reduction in his or her school hours to part-time
student status for a Medically Necessary reason). A Dependent child is defined as a student enrolled in
post-secondary education before the Medically Necessary leave of absence.
The child will continue to be a Dependent for one year after the first day of any verified Medically
Necessary leave of absence or, if earlier, the date coverage would otherwise terminate under the Plan
because the child does not satisfy the other eligibility requirements for Dependent coverage (e.g.,
because the child attains age 26).
QUALIFIED MEDICAL CHILD SUPPORT ORDERS
The Plan will also provide coverage as required by the terms of a Qualified Medical Child Support Order
(“QMCSO”). This coverage applies even if you do not have legal custody of the child; the child is not
dependent on you for support, and regardless of any enrollment restrictions that may otherwise exist for
Dependent coverage. If the Plan Administrator receives a valid QMCSO and you do not enroll the
Dependent child, the custodial parent or state agency may enroll the affected child. Additionally, the
Employer may withhold from your paycheck any contributions required for such coverage.
A QMCSO is a court order or court-approved settlement agreement that provides for health benefits for a
child of a group health plan participant or enforces one of the mandatory provisions of state law regarding
the provision of health insurance to minors in such cases. A QMCSO gives the child the same rights as
an Associate to receive benefits under a group health plan.
A QMCSO may be either a National Medical Child Support Notice issued by a state child support agency
or an order or a judgment from a state court or administrative body directing the Employer to cover a child
under the Plan. Federal law provides that a QMCSO must meet certain form and content requirements to
be valid. The Plan Administrator follows certain procedures to determine if a child support notice is
“qualified.” You may receive a copy of these procedures at no charge. If you have any questions, or
would like a copy of the child support order qualification procedures, please contact the Plan
Administrator.
WHO’S NOT ELIGIBLE
• Your common law spouse;
• Your legal spouse and/or child(ren) if covered under the Plan or other group health plan offered by
Trinity Health as an Associate or Dependent;
• Any individual who begins active service in the armed forces of any country, unless coverage is
continued as provided under the Uniformed Services Employment and Reemployment Rights Act of
1994 (“USERRA”); and
• Any individual who does not meet the definition of a benefits-eligible Associate or an eligible
Dependent as described in this Eligibility section of this SPD.
If you are ineligible for coverage, your spouse and your other Dependents are not eligible for coverage.
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PARTICIPATION
WHEN PARTICIPATION BEGINS
You may elect coverage under the Plan within 30 days of the date you are first eligible for coverage (your
“Initial Enrollment Period”) or during Annual Open Enrollment. If you are a newly hired benefits-eligible
Associate and you elect coverage for yourself during your Initial Enrollment Period (i.e., within 30 days of
your date of hire), your coverage will begin on the first day of the month after 30 days of employment with
your Employer, measured from your date of hire. If you are a newly hired benefits-eligible Associate and
you elect coverage for your eligible Dependents during your Initial Enrollment Period, your eligible
Dependents’ coverage will begin on the same day your coverage begins.
If you become a benefits-eligible Associate, as defined in your Employer’s policy that defines Associate
classifications, after your initial date of hire by your Employer, your coverage will begin on the first day of the
pay period following the date you become a benefits-eligible Associate (or the first day of the pay period
following the date you complete 30 days of employment with your Employer, if later) if you enroll yourself in
the Plan during your Initial Enrollment Period (i.e., within 30 days of the date you become a benefits-eligible
Associate). If you become a benefits-eligible Associate after your initial date of hire by your Employer and
you elect coverage for your eligible Dependents during your Initial Enrollment Period, your eligible
Dependents’ coverage will begin on the same day your coverage begins.
You must enroll yourself in the Plan in order to enroll your Dependents in the Plan.
The following table shows when participation begins for you and your covered Dependents:
Plan participant Qualified for coverage:
New hire First day of the month following 30 days of
employment
New Dependent: Spouse Date of marriage
New Dependent children: Newborn Date of birth through age 26
New Dependent children: Stepchildren Coverage begins date of marriage and continues
through age 26.
New Dependent children: Adopted, placed
for adoption and/or legal guardianship,
Coverage begins on the date of adoption,
placement for adoption, and/or legal guardianship.
Coverage continues through age 26.
Disabled Dependent children Must be Disabled before reaching age 26. To
remain covered under the Plan, you must notify
your Employer by the end of the calendar year in
which the Dependent reaches age 26.
Upon electing coverage under the Plan for your eligible Dependents, you will have 30 days to provide
documentation to verify the eligibility of each of your covered Dependents, including your spouse. The
required documentation is set forth in the Trinity Health Dependent Verification Documentation
Requirements, a copy of which can be obtained at http://mybenefits.trinity-health.org/
auditdocrequirements.pdf or from the Plan Administrator. Coverage for your Dependents will remain in an
“ineligible” status until appropriate documentation is provided. Failure to provide appropriate
documentation within 30 days will result in the voluntary termination of your election for coverage for your
Dependents.
NOTE: Certification of eligibility may be required periodically for your covered Dependents.
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During Annual Open Enrollment, you will make elections under the Plan for the following Plan Year.
Benefits coverage begins on January 1 of the new Plan Year and remains in effect for the entire Plan
Year (unless you change your coverage due to a special enrollment or change in status event described
below).
NOTE: If you and your spouse are employed by any Employer in a benefits-eligible position, you may
either both elect individual coverage or one of you may cover the other as a Dependent spouse. You
and/or your spouse are not eligible to be covered as both an Associate and a Dependent under the Plan.
In addition, if both you and your spouse are covered as Associates under the Plan, only one of you may
elect coverage for your Dependent children.
MAKING BENEFIT ELECTIONS
When you are eligible to participate in the Plan, you may enroll yourself and your eligible Dependent(s) by
following your Employer’s benefit enrollment process. When you first become eligible to enroll in the Plan and
during each Annual Open Enrollment period, you will be provided more detailed information about the
benefit plan choices, along with instructions about how to enroll and the enrollment deadline.
When you enroll, you will choose your benefit coverage level. Some Employers may offer Individual, Two
person or Family coverage levels from which you can choose. However, some Employers may offer
Employee Only, Employee and Child, Employee and Spouse, and Family coverage levels from which you
can choose.
You and your Employer share the cost of the coverage you elect under the Plan. Your contributions
toward the cost of this coverage will be deducted from your pay and are subject to change. Each year, the
benefit plans and the contributions for coverage are reviewed by Trinity Health and may be revised.
Information about Associate contributions is provided during Annual Open Enrollment. In addition, current
contribution amounts are available by contacting your Employer’s representative.
If you do not enroll in the Plan during your Initial Enrollment Period, you and your eligible Dependents will
not be eligible to enroll for coverage under the Plan until the next Annual Open Enrollment period (to be
effective on the first day of the next Plan Year) except under the circumstances described in the Special
Enrollment Periods section below or if you and/or your Dependents experience a change in status event
(described below). The Annual Open Enrollment period is held during the fall of each year.
SPECIAL ENROLLMENT PERIODS
If you do not elect coverage under the Plan for yourself and/or your eligible Dependents (including your
spouse) when you are first eligible to do so because of other health insurance coverage, you may enroll
yourself and/or your eligible Dependents in this Plan, if the other coverage is terminated as a result of
loss of eligibility for that coverage or termination of Employer contributions for the other coverage,
provided that you enroll within 30 days after you lose eligibility for the other coverage or the employer
contributions toward that other coverage end.
“Loss of eligibility” includes loss of coverage due to legal separation, death, divorce, termination of
employment in a class eligible for coverage, reduction in hours of employment, an individual ceasing to
be a Dependent under the coverage, termination of a benefit package option, if the coverage is provided
through an HMO, you no longer live or work in the HMO’s service area (and there is no other coverage
available under the plan), the exhaustion of COBRA continuation coverage; and the other employer no
longer contributing toward the cost of such coverage, or the plan no longer offers coverage to a class of
similarly situated individuals that includes you and/or your eligible Dependent (e.g., the plan terminates
coverage for all part-time employees but continues coverage for full-time employees, and you are a parttime
employee).
“Loss of Eligibility” does not include a loss of coverage due to failure to pay premiums or termination for
cause, such as making a fraudulent claim. If you do not elect coverage for yourself and/or your eligible
Dependents when you are first eligible to do so because you and/or your eligible Dependents have
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COBRA continuation coverage under another plan, you and/or your eligible Dependents must exhaust the
COBRA coverage before you and/or your eligible Dependents may enroll in this Plan under a special
enrollment period.
If you timely enroll, coverage under the Plan for you and/or your eligible Dependents will be effective on
the date the other coverage is terminated. If you do not timely enroll, enrollment for yourself and/or your
new eligible Dependent(s) must wait until the next Annual Open Enrollment period, to be effective at the
beginning of the next Plan Year (unless another event occurs which would allow you to enroll yourself
and/or your new eligible Dependent(s) prior to such time).
If you acquire a new eligible Dependent as a result of marriage, birth, adoption, or placement for
adoption, you will be entitled to special enrollment in the Plan if you meet one of the following conditions:
● Non-Enrolled Associate: If you are an eligible Associate but have not enrolled in the Plan, you may
enroll upon your marriage, or upon the birth, adoption, or placement for adoption of your child.
● Non-Enrolled Spouse: If you are an eligible Associate who is already enrolled in the Plan, you may
enroll your spouse at the time of his or her marriage to you. You may also enroll your spouse if you
acquire a child through birth, adoption, or placement for adoption.
● New Dependents of an Enrolled Associate: If you are an eligible Associate who is already enrolled
in the Plan, you may enroll a child who becomes your eligible Dependent as a result of marriage,
birth, adoption, or placement for adoption.
● New Dependents/Spouse of a Non-Enrolled Associate: If you are an eligible Associate but you are
not enrolled in the Plan, you may enroll a spouse or child, as applicable, who becomes your eligible
Dependent as a result of marriage, birth, adoption, or placement for adoption. However, you (the nonenrolled
Associate) must also be eligible to enroll in the Plan, and actually enroll in the Plan at the
same time.
You must enroll yourself and/or your new eligible Dependent(s) no later than 30 days after the date of the
event that entitles you and/or your eligible Dependent(s) to the special enrollment period. Coverage will
become effective as of the date of the event. If you do not timely enroll, enrollment for yourself and/or
your new eligible Dependent(s) must wait until the next Annual Open Enrollment period, to be effective at
the beginning of the next Plan Year (unless another event occurs which would allow you to enroll yourself
and/or your new eligible Dependent(s) prior to such time).
In addition to the above, under the Children’s Health Insurance Program Reauthorization Act of 2009, you
may enroll yourself and/or your eligible Dependent in the Plan if (1) you and/or your eligible Dependent
lose Medicaid or Children’s Health Insurance Program (“CHIP”) coverage due to no longer being eligible
for those benefits, or (2) you and/or your eligible Dependent become eligible for premium assistance in
the Plan under a Medicaid program or CHIP. You must enroll in the Plan due to one of these reasons no
later than 60 days after the date of the event that entitles you and/or your eligible Dependent to the
special enrollment period. If you enroll within 60 days after the date of the event, coverage will become
effective as of the date of the event. If you do not timely enroll, enrollment for you and/or your eligible
Dependent must wait until the next Annual Open Enrollment period, to be effective at the beginning of the
next Plan Year (unless another event occurs which would allow you to enroll yourself and/or your new
eligible Dependent prior to such time).
CHANGE IN STATUS
The benefit choices you make are in effect for one entire Plan Year and generally may be changed only
during the Annual Open Enrollment period. Elections you make during Annual Open Enrollment are
effective beginning January 1 of the following Plan Year. The exception to this rule prohibiting election
changes during a Plan Year is the occurrence of a special enrollment event described above or a
qualified change in status event described in this section. Qualified change in status events include the
following:
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• Change in marital status, including marriage, divorce, legal separation, annulment or death of spouse
• Change in number of Dependents, including birth, death, adoption, and placement for adoption
• Change in employment status of the Associate, spouse or Dependent child that causes you, your
spouse or Dependent child to either gain or lose eligibility for an employer’s benefit program,
including:
o Commencement or termination of employment,
o Change in worksite that removes the affected individual from a benefit plan’s service provider
area,
o Commencement or return from leave of absence, or
o Any employment status change that affects the eligibility of the individual to participate in a
benefit program or plan of an employer, including a change from part-time to full-time employment
or vice-versa, or a change from salaried to hourly pay, or, a strike or lockout.
• Change in residence of the Associate, spouse or Dependent that removes the affected individual from
the Plan’s service provider area (such a change entitles you to make a new Plan election selecting
another coverage option, but generally does not permit you to opt out of coverage entirely unless no
other relevant coverage is available).
• Dependent meeting or ceasing to meet the Plan’s definition of Dependent, such as attainment of a
specified age or a change in the Plan’s eligibility requirements.
• Cost or Coverage - A significant change in the cost or coverage of a benefit plan offered to you, your
spouse or other Dependent, including a new benefit option being added, a benefit option being
eliminated or significantly curtailed, a coverage change made under a plan offered by the Employer or
the employer of your spouse, former spouse or other Dependent, or a significant increase in the cost
of a benefit (such qualified change in status permits you to make a new benefit selection, but does
not allow you to revoke coverage entirely, unless no other similar coverage is available).
• You, your spouse or other Dependent become covered or lose benefit coverage under Medicare or
Medicaid, other than for pediatric vaccines.
• A judgment, decree or order requiring Dependent coverage (e.g., QMCSO).
• A special enrollment right you may be entitled to under the provisions of the Health Insurance
Portability and Accountability Act of 1996, as amended (“HIPAA”).
• You commence or return from an unpaid leave of absence as permitted and regulated by the Family
Medical Leave Act (“FMLA”).
• A change in coverage under another employer’s group health plan if the other group health plan
permits participants to make an election change under the circumstances listed above or an election
of coverage by your spouse, former spouse or Dependent during an open enrollment period under
another employer’s group health plan that differs in time from the Annual Open Enrollment period.
If you want to make an election change due the occurrence of a qualified change in status event, you
must make the election change within 30 days after the date that the event occurs. Appropriate
documentation is required. You may only make changes to benefit coverage under the Plan that are
consistent with the qualified change in status event. For example, if the documentation you provide is for
the birth of a child, you may increase your benefit coverage level to two person or family; however you
cannot decrease the benefit coverage level or opt out of coverage.
If you make an election change due to the occurrence of a change in status event within 30 days after the
event occurs, the change will be effective as soon as administratively practicable but not earlier than the
first pay period after a new election is made and returned to the Plan Administrator. Qualified change in
status events shall only be effective as to contributions and benefits under the Plan on and after the
17

effective date of such change. However, election changes made due to a special enrollment right as
provided by HIPAA may result in coverage being made available retroactively to the date of the qualified
change in status event.
ENROLLING AFTER YOU WAIVE PARTICIPATION
If you choose not to participate in the Plan, your next opportunity to enroll will be during the next Annual
Open Enrollment unless you have a qualified change in status event or there is a special enrollment right.
LEAVES OF ABSENCE
If you are not at work due to an unpaid, Employer-approved leave of absence, period of military service
lasting more than 30 days, or any other reason that creates a legal obligation for the Employer to extend
coverage under the Plan, you may, at your option, continue coverage during the period of absence in
accordance with your Employer’s leave of absence policy.
If you are absent from work for any paid leave of absence you must continue the coverage you elected
under the Plan and your contributions for the coverage will continue to be deducted from your paychecks
during the absence.
If your Employer is subject to the Family and Medical Leave Act of 1993, as amended (the “FMLA”), then
the FMLA policies of your Employer shall control. You should refer to your Employer’s internal FMLA
policies for further guidance on FMLA leave.
REHIRED ASSOCIATES
If you separate from service with your Employer before becoming a participant and you are later reemployed
by your Employer, you must satisfy the eligibility requirements in order to participate in the Plan
without regard to any prior period of employment with an Employer.
If you separate from service with your Employer after becoming a participant and you are rehired into a
benefits-eligible position in the same Plan Year, you (and your Dependents, if applicable) will immediately
participate in the Plan on your reemployment date. You will have the opportunity to re-elect your benefits
at this time or to be re-enrolled in the benefit options you had previously elected.
NOTE: Amounts previously credited toward your plan accumulators (i.e. deductible, out-of-pocket
maximum) within a calendar year will be carried forward.
WHEN COVERAGE ENDS
Your participation in this Plan will end on the earliest of the following dates:
• The last day of the pay period in which your employment with your Employer ceases;
• The date of your death;
• The last day of the pay period in which a change in employment status occurs that affects your
eligibility to participate in the Plan (i.e., reduction in hours that causes you to be ineligible to
participate);
• The last day of the pay period in which you make a contribution toward the cost of coverage under
the Plan; or
• The date the Plan is terminated.
Your spouse’s coverage under the Plan will end on the earliest of:
• The date of your divorce or legal separation;
• The last day of the pay period in which your employment with your Employer ceases;
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• The last day of the pay period in which your death occurs;
• The last day of the pay period in which a change in employment status occurs that affects your
eligibility to participate in the Plan (i.e., reduction in hours that causes you to be ineligible to
participate);
• The last day of the pay period in which you make a contribution toward the cost of coverage under
the Plan; or
• The date the Plan is terminated.
Your Dependent child’s coverage under the Plan will end on the earliest of:
• The last day of the Plan Year in which the child turns age 26 (or ceases to satisfy the requirements
set forth in the Eligibility section of the SPD for Disabled children to be eligible for coverage after they
reach age 26);
• The last day of the pay period in which your employment with your Employer ceases;
• The last day of the pay period in which your death occurs;
• The last day of the pay period in which a change in employment status occurs that affects your
eligibility to participate in the Plan (i.e., reduction in hours that causes you to be ineligible to
participate);
• The last day of the pay period in which you make a contribution toward the cost of coverage under
the Plan; or
• The date the Plan is terminated.
Your coverage and your Dependent’s coverage under the Plan will cease at the times described above
unless COBRA continuation coverage is elected as shown in the Continuation of Group Health Coverage
section on page 24.
The Plan may not rescind an individual’s coverage unless such individual fails to pay the required
premiums or contributions toward the cost of coverage under the Plan, or such individual commits fraud
with respect to the Plan or makes an intentional misrepresentation of a material fact.
When you and/or your Dependent(s) lose coverage under the Plan, you and/or your Dependent(s) (as
applicable) will be provided with a Certificate of Creditable Coverage as required by HIPAA. The
Certificate of Creditable Coverage will indicate the time period that you or your Dependent(s) were
covered by the Plan, subject to HIPAA’s portability requirements. You and/or your Dependent(s) may also
request a Certificate of Creditable Coverage within 24 months of losing coverage under the Plan. If you
and/or your Dependent(s) need to request a Certificate of Creditable Coverage, you and/or your
Dependent(s) can do so by contacting the Plan Administrator. The request must be in writing and must
include: (1) the name(s) of the individual(s), (2) the time period to be covered by the Certificate of
Creditable Coverage, and (3) a mailing address where the Certificate of Creditable Coverage should be
sent.
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COORDINATION OF BENEFITS
The Plan’s coordination of benefits (“COB”) procedures will apply when you or your covered Dependents
are covered under both the Plan and another health care plan, such as one provided by your spouse’s
employer, Medicare or a no-fault insurance policy.
COORDINATING WITH ANOTHER EMPLOYER’S PLAN
COB is how plans coordinate benefits when you are covered by more than one health care or motor
vehicle insurance plan or policy. The Plan, which is administered by the Plan Administrator and the
Claims Administrator, requires that your benefit payments be coordinated with benefit payments from
another health care or motor vehicle insurance plan or policy for services and/or supplies that may be
payable under either plan, so that payment responsibilities will be fair. If you are covered by more than
one health care or motor vehicle insurance plan or policy, COB guidelines (explained below) determine
which plan pays for Covered Services first. COB letters of inquiry, which request information about other
plans, may be sent on an annual or more frequent basis in order to keep the Plan’s records up to date.
The plan that pays first is your primary plan. This plan must provide you with the maximum benefits
available to you under that plan. The plan that pays second is your secondary plan. This plan provides
payments toward the balance of the cost of Covered Services — up to the total allowed amount under
that plan.
COB makes sure that the level of payment, when added to the benefits payable under another plan, will
cover up to the total of the eligible expenses. COB also makes sure that the combined payments of all
coverage will not exceed the actual cost approved for your care.
GUIDELINES TO DETERMINE WHICH PLAN IS PRIMARY AND SECONDARY
When both this Plan, paying as secondary, and the primary plan have a preferred Provider arrangement
in place, payment will be made up to the preferred Provider allowance available to the primary plan.
NOTE: For information regarding coordination with Medicare, please refer to the section of this SPD titled
Coordination With Medicare.
If the claimant is an active Associate this Plan will be primary to:
• A plan covering the claimant as a Dependent;
• A plan covering the claimant as a COBRA participant;
• A plan covering the claimant as a retiree in another group health plan; or
• A plan covering the claimant as a Dependent of a retiree in another group plan.
If the claimant is the spouse of an active Associate this Plan will be primary to a plan covering the spouse
as a COBRA participant.
This Plan will be secondary to:
• A plan covering the spouse as a retiree, or
• A plan covering the spouse as an active Associate.
If the claimant is the child of an active Associate this Plan will be primary to a plan covering the child as a:
• Dependent of the Associate’s spouse, provided the spouse is also an active employee, if the
Associate’s birthday (day and month) is earlier in the year than the Associate’s spouse’s birthday
• COBRA participant or a Dependent of a COBRA participant;
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• CHIP participant; or
• Dependent of a retiree.
If both parents have the same birth date, the coverage that has been in effect the longest will be
primary for the Dependent child.
This Plan will be secondary to a plan covering the child as a Dependent of the Associate’s spouse
provided the spouse is also an active employee, if the Associate’s birthday (day and month) is later in the
year than the Associate’s spouse.
If the claimant is a child of an active Associate and a court decree designates financial
responsibility or establishes which parent must provide primary coverage and/or the order of payment,
this Plan will follow the court decree.
If rules are not established, this Plan will pay in the following order:
• The plan that covers the parent who has custody of the child.
• The plan that covers the step-parent who has custody of the child.
• The plan which covers the parent who does not have custody of the child.
• The plan that covers the step-parent who does not have custody of the child.
If there is a court decree that orders joint custody and does not determine primary status for benefit
coverage, the Plan’s regular provisions establishing the primary status for children of active Associates
will apply.
If the claimant is a COBRA participant in this Plan, this Plan will be secondary to a plan covering the
claimant as:
• An active employee;
• A Dependent of an active employee;
• A retiree; or
• A Dependent of a retiree.
If a claimant is covered by another plan as a COBRA participant then the primary plan will be the plan in
effect the longest. Notwithstanding the above, if a plan has no COB provision, it will always be primary.
COORDINATION WITH MEDICARE
Active Associates or Dependents of active Associates eligible for Medicare due to age
If you are covered under this Plan due to your or someone else’s current employment with the Employer,
and are also eligible for Medicare due to age, you may:
• Continue your coverage under this Plan (to the extent you remain eligible) and defer enrollment in
Medicare; or
• Continue your coverage under this Plan and also enroll in Medicare; this Plan would be your primary
medical coverage and Medicare would be your secondary medical coverage as long as your
coverage under this Plan is attributable to current employment with the Employer; or
• Drop your coverage under this Plan and enroll in Medicare, in which case Medicare would be your
primary medical coverage.
Covered Individuals eligible for Medicare due to disability
This Plan is primary and Medicare is secondary if you are eligible for Medicare by reason of disability (but
not age), and your coverage under this Plan is on account of your (or someone else’s) current
21

employment with the Employer. If coverage under this Plan is not on account of current employment
status with the Employer, and you are eligible for Medicare solely by reason of disability, Medicare is
primary and this Plan is secondary. Note that in this latter case – where this Plan is secondary – this Plan
will deem you or your Dependent, to be enrolled in Medicare Parts A, B and D even if you or your
Dependent have not so enrolled.
Medicare eligibility by reason of end stage renal disease
This Plan is primary and Medicare is secondary if you are eligible for Medicare solely on the basis of End
Stage Renal Disease (“ESRD”), are not eligible for Medicare by reason of age or disability, and your
coverage under this Plan is on account of your (or someone else’s) current employment with the
Employer. However, this Plan is primary only during the first 30 months of such eligibility for Medicare
benefits. This 30-month period generally begins on the earlier of:
• The first day of the fourth month during which a regular course of renal dialysis starts; or
• If you receive a kidney transplant, the first day of the month during which you become eligible for
Medicare.
If you are eligible for Medicare solely on the basis of ESRD, you must be covered by Parts A and B to get
the full benefits available under Medicare to cover ESRD treatment. You may also enroll in Part D if you
need coverage for certain prescribed drugs that may not be covered under Part B. If you enroll in
Medicare Part A and defer enrolling in Part B during the 30-month coordination period, you will be
charged a premium penalty by Medicare when you enroll in Part B if you delay enrolling by 12 or more
months. In addition, this provision does not apply if at the start of your eligibility for this Plan you were
already eligible for Medicare benefits and this Plan’s benefits were payable on a secondary basis.
In order to assist your Employer and the Claims Administrator in complying with Medicare Secondary
Payer (“MSP”) laws, it is very important that you promptly and accurately complete any requests for
information from the Claim Administrator and/or your Employer regarding the Medicare eligibility of you,
your spouse and covered Dependent children. In addition, if you, your spouse or covered Dependent
child becomes eligible for Medicare, or has Medicare eligibility terminated or changed, please contact
your Employer or the Claim Administrator promptly to ensure that your claims are processed in
accordance with applicable MSP laws.
UPDATING COB INFORMATION — YOUR RESPONSIBILITY
It is important to keep your COB records updated. If there are any changes in coverage information for
you or your Dependents, notify your Employer and the Claims Administrator immediately. Please help the
Plan Administrator and Claims Administrator serve you better by responding to requests for COB
information quickly. The Plan will request updated COB information at least yearly. If COB information
such as cancellation of other coverage, switching other coverage carriers or changes in custody or court
ordered coverage for Dependent children is not updated, claims could be rejected inappropriately or
incorrect information may be sent to your health care providers.
If the information you provided on your latest COB letter of inquiry is more than one year old and a claim
is submitted under the Plan for you, your spouse or your Dependent children, the claim will be temporarily
held. The Claims Administrator will send you a new letter of inquiry requesting information about other
carriers. When you respond, the Claims Administrator will update your record. The claim will then be
processed according to the appropriate COB rules.
Important: If you do not respond to the Claims Administrator’s letter of inquiry within 45 days of its
receipt, the claim will be denied due to lack of current COB information. In addition, all other claims for
you, your spouse and your Dependents will be denied until the COB letter of inquiry is returned.
22

SPECIFIC INFORMATION ABOUT YOUR COB
The Plan includes non-duplicative payment COB. This means:
• When the Plan is the secondary (or tertiary) payer, you remain responsible for all primary patient
liability resulting from primary insurance sanctions, penalties or Network restrictions, unless your
primary insurer is an HMO.
• As secondary (or tertiary) payer, the Plan will not apply contract Network restrictions unless the
primary insurer denied benefits for the service.
• As secondary (or tertiary) payer, the Plan will cover the remaining non-sanctioned patient liability up
to the amount the Plan would have paid had the Plan been primary for Covered Services only.
FILING COB CLAIMS TO YOUR SECONDARY CARRIER
You must always (or must always have your health care provider) submit claims to your primary carrier
first. Then you or your Provider should submit a claim for the secondary balance to the Claims
Administrator. If your Provider will not submit a secondary claim to the Claims Administrator, then you can
submit the claims as follows:
1) Obtain an explanation of benefits from the primary carrier
2) Ask your Provider for an itemized receipt or detailed description of the services, including charges for
each service
3) If you made any payments for the service, provide a copy of the receipts you received from the
Provider
4) Make sure the Provider’s name and complete address is on your receipts. Also include the Provider’s
tax ID number
5) Send these items to the appropriate address as indicated on the claim
Please make copies of all forms and receipts for your own files, because the Claims Administrator cannot
return the originals to you.
NO-FAULT AUTO COVERAGE
If you are involved in a motor vehicle accident, payment for medical services will be coordinated between
the Plan and your auto insurance carrier as follows:
• Whether your auto coverage is coordinated or uncoordinated, your auto insurance carrier is primary.
• The Plan will be secondary to your no-fault auto insurance. The Medical Claims Administrator will
reject auto accident related claims received without proof of primary payment by the auto insurer.
It is important that you discuss this with your auto insurance company.
SUBMITTING COORDINATED CLAIMS
Claims for benefits should first be sent to the claims administrator of the plan that pays first. Then, after
receiving an Explanation of Benefits (“EOB”) form, a claim should be submitted to the plan that pays
second for processing of any unpaid expenses.
If you send the claim to the secondary plan before receiving an EOB from the primary plan, there will be a
delay in processing the payment and may result in a rejection of the claim.
23

CONTINUATION OF GROUP HEALTH COVERAGE
Continued coverage is available as required by law under the Consolidated Omnibus Budget
Reconciliation Act of 1985, as amended (“COBRA”).
If your (or your Dependent’s) coverage under the Plan would otherwise end because of any qualifying
event (see below), then you (or your Dependent) have the right to continue group health coverage under
the Plan if you (or your Dependent) were covered under the Plan on the day immediately preceding the
qualifying event. Your child who is born or placed for adoption with you during a COBRA continuation
coverage period is also a qualified beneficiary.
An individual who elects to continue coverage will be required to pay the full cost of the coverage plus an
applicable administration fee. The time period for which the continuation is available is set forth below in
conjunction with the corresponding qualifying event. If continuation of coverage is elected, coverage will
continue as though termination of employment or loss of eligible status had not occurred. If any changes
are made to the coverage for Associates in active service, the coverage provided to individuals under this
continuation provision will be changed similarly.
QUALIFYING EVENTS
Continuation coverage is available for up to eighteen (18) months to eligible individuals who would lose
coverage under the Plan due to either of the following qualifying events:
• The Associate’s termination of employment with his or her Employer for any reason except gross
misconduct; or
• Reduced work hours of the active Associate.
Continuation coverage is available for up to thirty-six (36) months to a covered Dependent spouse and/or
child who would lose coverage under the Plan due to any one of the following qualifying events:
• Your death;
• You and your spouse become divorced or are legally separated;
• Loss of eligibility of Dependent child status under the Plan; or
• Loss of eligibility due to you becoming covered by Medicare (under Part A, Part B, or both).
When the qualifying event is the termination of the Associate’s employment or reduction of the
Associate’s hours of employment, and the Associate became entitled to Medicare benefits less than 18
months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than
the Associate lasts until 36 months after the date of Medicare entitlement. For example, if a covered
Associate becomes entitled to Medicare eight months before the date on which his or her employment
terminates, COBRA continuation coverage for his or her spouse and children can last up to 36 months
after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event
(36 months minus eight months). Otherwise, when the qualifying event is the termination of an
Associate’s employment or reduction of the Associate’s hours of employment, COBRA continuation
coverage generally lasts for only up to a total of 18 months. There are two ways in which this 18-month
period of COBRA continuation coverage can be extended:
1) Disability Extension Of 18-Month Period Of Continuation Coverage
If you or anyone in your family covered under the Plan is determined by the Social Security
Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and your
entire family may be entitled to receive up to an additional 11 months of COBRA continuation
coverage, for a total maximum of 29 months. The disability would have to have started at some time
before the 60th day of COBRA continuation coverage and must last at least until the end of the 18–
month period of continuation coverage. You must make sure that the Plan Administrator is
24

notified of the Social Security Administration's determination within 60 days of the later of: (i)
the date of the qualifying event (the Associate’s termination of employment or reduction in
hours); (ii) the date of the Social Security Administration determination; or (iii) the date on the
qualified beneficiary loses (or would lose) coverage under the Plan as a result of the
qualifying event. In addition, you must notify the Plan Administrator of the Social Security
Administration’s determination before the end of the 18-month period of COBRA continuation
coverage.
2) Second Qualifying Event Extension Of 18-Month Period Of Continuation Coverage
If your family experiences another qualifying event while receiving 18 months of COBRA continuation
coverage, the spouse and Dependent children in your family can get up to 18 additional months of
COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event
is properly given to the Plan Administrator. This extension may be available to the spouse and
Dependent children receiving continuation coverage if the Associate or former Associate dies,
becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally
separated or if the Dependent child stops being eligible under the Plan as a Dependent child, but only
if the event would have caused the spouse or Dependent child to lose coverage under the Plan had
the first qualifying event not occurred. In all of these cases, you must make sure that the Plan
Administrator is notified of the second qualifying event within 60 days of the second
qualifying event.
ELECTION OF COVERAGE
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan
Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end
of employment or reduction of hours of employment, death of the Associate, commencement of a
proceeding in bankruptcy with respect to the Employer or enrollment of the Associate in Medicare (Part A,
Part B or both), the Employer must notify the Plan Administrator of the qualifying event within 30 days of
any of these events. For other qualifying events (divorce or legal separation, or because a child is no longer
eligible to be a Dependent), the Associate or covered Dependent (or any representative) MUST notify the
Plan Administrator within 60 days after the qualifying event occurs or COBRA continuation
coverage will not be offered.
Once the Plan Administrator receives notice that a qualifying event has occurred, a COBRA election
notice will be provided to each of the qualified beneficiaries (within 14 days after receiving notice of the
qualifying event). Each qualified beneficiary will have 60 days to elect COBRA coverage from the later of
the date the election notice is sent or the date on which coverage under the Plan would be lost due to the
qualifying event. For each qualified beneficiary who elects COBRA continuation coverage, COBRA
continuation coverage will begin on the date that Plan coverage would otherwise have been lost. Each
qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered
Associates may elect COBRA continuation coverage on behalf of their spouses, and parents may elect
COBRA continuation coverage on behalf of their children.
REQUIREMENTS FOR ALL NOTICES
The qualifying event notice and second qualifying event notice must be sent within the applicable
time(s) set forth above to the Plan Administrator at the address listed for the Plan Administrator
on page 43 of this SPD. The notice must be in writing and must include: (1) the Plan name, (2) the
name of the Associate and the disabled qualified beneficiary, if different, (3) the date of the Social
Security Administration's determination of disability, and (4) a copy of the Social Security
Administration’s determination of disability. The Associate, the qualified beneficiary or any
representative on behalf of the Associate or the qualified beneficiary can provide the notice.
25

COST OF CONTINUATION OF COVERAGE
The cost of continuation of coverage for each individual generally is an amount equal to 102 percent of
the total cost to the Plan for the period of coverage for similarly situated covered Associates, spouses or
other Dependents, for whom a qualifying event has not occurred (including the portion of such cost paid
by both the Employer and Associate for active Associates and their Dependents). However, if a qualified
beneficiary has elected to extend his or her COBRA continuation coverage as a result of Disability, the
cost of continuation coverage shall be 150 percent of the cost to the Plan during the 11-month extension
that occurs after the original 18-month continuation coverage period, or such longer period as may be
available due to the occurrence of another qualifying event during the disability extension period.
Payment of the initial premium is considered timely if it is received within forty-five (45) days after a timely
COBRA continuation coverage election. All subsequent payments for COBRA continuation coverage are
due and payable on the first day of each calendar month for which COBRA continuation coverage is
desired. However, premium payments will be considered timely if they are made within 30 days of the
premium payment due date.
TERMINATION OF CONTINUATION OF COVERAGE
A qualified beneficiary’s continuation coverage will terminate prior to time periods set forth above in the
following situations:
• The Employer ceases to provide any group health plan for Associates
• Any required premium is not paid in full on time
• The qualified beneficiary becomes covered, after electing COBRA continuation coverage, under any
other group health plan without being subject to any exclusions or limitations with respect to a preexisting
condition
• The qualified beneficiary becomes covered by Medicare (under Part A, Part B, or both) after electing
COBRA continuation coverage
• The qualified beneficiary engages in conduct that would justify the Plan in terminating coverage of a
similarly situated participant or beneficiary not receiving continuation coverage (such as fraud)
• With respect to coverage in excess of 18 months by reason of disability, the end of the first month
that begins after a final determination under the Social Security Act that the disabled individual is no
longer disabled
TRADE ACT OF 1974
Special COBRA rights may apply to you if you have been terminated or experienced a reduction of hours and
you qualify for a “trade readjustment allowance” or “alternative trade adjustment assistance” under a Federal
law called the Trade Act of 1974 (as reauthorized by the Trade Adjustment Assistance Reform Act of 2002).
If you qualify for these special rights, you may be entitled to a second opportunity to elect COBRA coverage
for yourself and certain family members (if COBRA coverage has not already been elected), but only within a
limited period of 60 days (or less) and only during the six months immediately after your group health plan
coverage ended. In addition, a special tax credit may be available to you if you are an eligible individual.
If you were terminated or experienced a reduction of hours that qualifies for a trade readjustment
allowance or alternative trade adjustment assistance, please see the Administrator regarding additional
rights that may be applicable to you. If you have questions about the tax credit provisions in the Act, you
may call the Health Coverage Tax Credit Consumer Contact Center toll-free at 1-866-628-4282. TTD/TTY
callers may call toll-free at 1-866-626-4282. More information about the Trade Act is also available at
www.doleta.gov/tradeact.
26

USERRA CONTINUATION COVERAGE
If you perform service in the uniformed services you may elect up to 24 months of continuation coverage
under the Plan, as required by the Uniformed Service Employment and Reemployment Rights Act
(“USERRA”). The procedures set forth for electing COBRA continuation coverage apply to this election for
continuation coverage. Contact the Plan Administrator for additional information about USERRA
continuation coverage.
IF YOU HAVE QUESTIONS
If you have questions concerning the Plan or COBRA continuation coverage, please feel free to contact
the Plan Administrator. For more information about your rights under the Employee Retirement Income
Security Act of 1974, as amended (“ERISA”), including COBRA, HIPAA, and other laws affecting group
health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee
Benefits Security Administration (“EBSA”) in your area or visit the EBSA website at www.dol.gov/ebsa.
(Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s
website.)
KEEP THE PLAN INFORMED OF ADDRESS CHANGES
In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in
the addresses of family members. You should also keep a copy, for your records, of any notices you send
to the Plan Administrator.
27

PLAN ADMINISTRATION INFORMATION
EMPLOYMENT RIGHTS
Nothing in the Plan or this SPD in any way creates an expressed or implied contract of employment or
constitutes or provides a promise or guarantee of employment or continued employment. Nor do these
documents change any such employment relationship to be other than employment “at will.” Your
employment may be suspended, changed, or otherwise terminated by either you or your Employer at any
time.
NO WARRANTY OF HEALTH CARE PROVIDERS
The Plan provides payment for Covered Expenses. The Plan, Trinity Health and the other participating
Employers make no warranties or representations regarding the delivery or quality of care.
DESIGNATION OF FIDUCIARY RESPONSIBILITY
Trinity Health is the named fiduciary with respect to this Plan, within the meaning of Section 402(a)(1) of
ERISA. Trinity Health shall exercise all discretionary authority and control with respect to management of this
Plan, which is not specifically granted to another fiduciary.
Trinity Health may delegate certain of its fiduciary responsibilities under this Plan to persons who are not
named fiduciaries of the Plan. If fiduciary responsibilities are delegated to any other person, except as
otherwise required by ERISA, such delegation of responsibility shall be made by written instrument executed
by Trinity Health a copy of which will be kept with the records of this Plan.
Aetna has, by written instrument, been designated as the fiduciary for appeals of adverse benefit
determinations for medical claims submitted to the Plan. By making this designation, it is Trinity Health’s
intention that Aetna make final claim determinations and have final discretion in construing the terms of the
Plan with respect to final medical claim determinations. Aetna shall not be responsible for any fiduciary
responsibilities other than those outlined in this paragraph.
CVS Caremark has, by written instrument, been designated as the fiduciary for appeals of adverse benefit
determinations for prescription claims submitted to the Plan. By making this designation, it is Trinity Health’s
intention that CVS Caremark make final claim determinations and have final discretion in construing the
terms of the Plan with respect to final Prescription Drug claim determinations.
Each fiduciary under this Plan shall be solely responsible for its own acts or omissions. Except to the extent
required by ERISA, no fiduciary shall have the duty to question whether any other fiduciary is fulfilling all of
the responsibilities imposed upon such other fiduciary by federal or state law. No fiduciary shall have any
liability for a breach of fiduciary responsibility of another fiduciary with respect to this Plan unless it
participates knowingly in such breach, knowingly undertakes to conceal such breach, has actual knowledge
of such breach, fails to take responsible remedial action to remedy such breach or, through its negligence in
performing its own specific fiduciary responsibilities which give rise to its status as a fiduciary, it enables such
other fiduciary to commit a breach of the latter's fiduciary responsibility.
No fiduciary shall be liable with respect to a breach of fiduciary duty if such breach is committed
before it became a fiduciary, and nothing in this Plan shall be deemed to relieve any person from
liability for his or her own misconduct or fraud.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (“HIPAA”)
HIPAA was enacted, among other things, to improve the portability and continuity of health care
coverage. In addition, HIPAA contains provisions designed to protect the security and privacy of health
care information. The following are summaries of HIPAA’s primary impact on the Plan.
28

Privacy of Health Information
HIPAA requires that health plans protect the confidentiality of private health information. The Plan may
have access to certain private health information about you and your covered Dependents. This
information is necessary to administer claims and provide benefits under the Plan. The Plan understands
and recognizes the confidentiality and sensitivity of your health information and is committed to protecting
this information from inappropriate uses and disclosures.
The Plan and its business associates (which are generally, people or entities that perform certain
functions or activities that involve the use or disclosure of protected health information on behalf of, or
provides services to, the Plan) may use and disclose information about you that is protected by HIPAA
(referred to as “protected health information” or “PHI”) without your consent, written authorization or
opportunity to agree or object for treatment, payment, and health plan operations. The Plan and its
business associates may also use or disclose your PHI without your consent as required by law. The Plan
and its business associates will disclose your PHI to your personal representative when the personal
representative has been properly designated through appropriate written documentation. In addition, you
may authorize the use or disclosure of your PHI to another person and for the purpose you designate. If
you grant an authorization, you may withdraw it, in writing, at any time. Your withdrawal will not affect any
use or disclosures permitted by your authorization while it was in effect. The Plan, its business associates
and Trinity Health will not, without your authorization, use or disclose PHI for employment-related actions
and decisions or in connection with any other benefit or employee benefit plan of Trinity Health.
Under HIPAA, you have certain rights with respect to your protected health information, including certain
rights to see and copy the information, to receive an accounting of certain disclosures of the information
and, under certain circumstances, to amend the information. You also have the right to file a complaint
with the Plan or with the Secretary of the U.S. Department of Health and Human Services if you believe
your rights under the HIPAA privacy rules have been violated.
As required by HIPAA, the Trinity Health Welfare Benefit Plan (“Welfare Plan”) has adopted certain
privacy policies and procedures related to the use and disclosure of your PHI. You will receive a copy of
the Welfare Plan’s Notice of Privacy Practices (the “Notice”) that outlines how and when the Plan can use
or disclose your PHI as well as your rights and protections under the law. If there are material changes
made to the Welfare Plan’s practices and procedures regarding the use and protection of your PHI, you
will receive a revised Notice. In addition, you may receive a copy of the Notice at any time by contacting
the Welfare Plan’s Privacy Officer at:
Trinity Health
34605 Twelve Mile Road
Farmington Hills, MI 48331
The Welfare Plan has appointed its Privacy Officer to oversee the Welfare Plan’s compliance with
the HIPAA privacy rules and to address complaints. If you have any questions about how the Plan
protects your PHI and your question is not answered by reviewing the information in the Notice, if
you would like more information about the Welfare Plan’s privacy practices or if you want to make
a complaint about the Welfare Plan’s privacy activities, contact the individual(s) identified in the
Notice.
Non-Discrimination Due to Health Status
Any rule for eligibility that discriminates based on a “health factor” of an Associate or a Dependent of that
Associate is prohibited. For instance, the Plan is prohibited from containing an actively-at-work
requirement that is based on a health factor of an Associate. An exception is made with regard to an
Associate’s first day of work (e.g., if an individual does not report to work on his/her first scheduled work
day he/she need not be covered and any waiting period for coverage need not begin). Similarly, a
Dependent cannot be refused enrollment or coverage based on a “health factor” such as confinement in a
health care facility.
29

A “health factor” means any of the following:
• Health status;
• A medical condition (whether physical or mental condition);
• Claims experience;
• Receipt of health care;
• Medical history;
• Evidence of insurability (including conditions arising out of acts of domestic violence and participation
in certain recreational activities, including high-risk activities);
• Disability; and
• Genetic information.
“Rules for eligibility” include, but are not limited to, rules relating to:
• Enrollment;
• The effective date of coverage;
• Waiting (or affiliation) periods;
• Late and special enrollment;
• Eligibility for benefit packages (including rules for individuals to change their selection among benefit
packages);
• Benefits (including rules related to covered benefits, benefit restrictions, and cost-sharing
mechanisms such as Coinsurance, Copayments and Deductibles);
• Continued eligibility; and
• Terminating coverage of any individual under a Plan.
NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT OF 1996
The Plan may not, under Federal law, restrict benefits for any Hospital length of stay in connection with
childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than
96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or
newborn’s attending Provider, after consulting with the mother, from discharging the mother or her
newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under
Federal law, require that a Provider obtain authorization from the plan or the insurance issuer for
prescribing a length of stay not in excess of 48 hours (or 96 hours).
WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998
As required by the Women’s Health and Cancer Rights Act of 1998 (the “WHCRA”), since the Plan
provides medical and surgical benefits for mastectomies, the Plan also provides coverage for
reconstructive surgery and related services related that may follow mastectomies. In compliance with the
WHCRA, the Plan covers:
● Reconstruction of the breast on which the mastectomy was performed;
● Reconstruction and Surgery of the other breast to achieve symmetry between the breasts; and
● Prostheses and treatment of physical complications of all stages of the mastectomy (including
lymphedema).
30

Coverage will be provided in a manner determined in consultation with the attending Physician and the
patient. The Plan’s Deductibles, Coinsurance, and Copayments that are in effect at the time service is
provided will apply to the coverage described above.
PLAN ADMINISTRATOR POWERS
The Plan Administrator is empowered and authorized to make rules and regulations and establish
procedures with respect to the Plan and to determine or resolve all questions that may arise as to the
eligibility, benefits, status and right of any person claiming benefits under the Plan. The Plan
Administrator has the power and discretionary authority to construe and interpret the Plan and to correct
any defect, supply any omissions, or reconcile any inconsistencies in the Plan, and generally do all other
things which need to be handled in administering this Plan.
The exercise of the Plan Administrator’s authority shall be binding upon all interested parties, including,
but not limited to Covered Individuals, their estates and their beneficiaries, and shall be subject to review
only if it is arbitrary or capricious or otherwise inconsistent with applicable law.
The Plan Administrator will determine eligibility for benefits under the Plan. The Plan Administrator has
delegated fiduciary responsibility for medical claims to Aetna and has delegated fiduciary responsibility for
Prescription Drug claims to CVS Caremark. The Plan shall be governed by and interpreted according to
ERISA and the Internal Revenue Code and, where not pre-empted by Federal law, the laws of the state
of Michigan.
FILING A CLAIM FOR BENEFITS AND REVIEW PROCEDURES
You may file claims for benefits, and appeal adverse claim decisions, either yourself or through an
Authorized Representative.
HOW TO SUBMIT A CLAIM FOR BENEFITS
A claim must be filed before a benefit payment can be made. There are three (3) types of claims:
• A “pre-service claim” means a claim for a benefit where your plan conditions receipt of the benefit, in
whole or in part, on obtaining approval in advance of receiving medical care.
• An “urgent care claim” means a pre-service claim for medical care or treatment where the time
periods for non-urgent predeterminations could seriously jeopardize your life, health, ability to regain
maximum function or, in the opinion of a Physician who knows your medical condition, would subject
you to severe pain that cannot be adequately managed without the care or treatment you are
seeking.
If a Physician with knowledge of your medical condition determines that the claim is one involving
urgent care, the Plan Administrator or its delegate will treat it as such. Absent a determination by your
Physician, the Plan Administrator or its delegate will determine whether a claim is one involving
urgent care by using the judgment of a prudent layperson with average knowledge of health and
medicine.
• A “post-service claim” means all other claims that are not “pre-service claims” or “urgent care claims”.
The Plan Administrator has delegated its authority to make claim determinations, other than claim
determinations with respect to Prescription Drug claims, to Aetna, the Medical Claims Administrator. You
or your Authorized Representative generally must file claims in writing with your Aetna customer service
office at:
Aetna Life Insurance Company
151 Farmington Avenue
Harford, CT 06156
31

REPORTING OF CLAIMS
A claim must be submitted to Aetna in writing. It must give proof of the nature and extent of the loss. Your
employer has claim forms.
All claims should be reported promptly. The deadline for filing a claim is 90 days after the date of the loss.
If, through no fault of your own, you are not able to meet the deadline for filing claim, your claim will still
be accepted if you file as soon as possible. Unless you are legally incapacitated, late claims for health
benefits will not be covered if they are filed more than 2 years after the deadline.
CLAIMS, APPEALS AND EXTERNAL REVIEW
FILING HEALTH CLAIMS UNDER THE PLAN
Under the Plan, you may file claims for Plan benefits and appeal adverse claim determinations. Any
reference to you in this Claims, Appeals and External Review section includes you and your Authorized
Representative. An "Authorized Representative" is a person you authorize, in writing, to act on your
behalf. The Plan will also recognize a court order giving a person authority to submit claims on your
behalf. In the case of an urgent care claim, a health care professional with knowledge of your condition
may always act as your Authorized Representative.
If your claim is denied in whole or in part, you will receive a written notice of the denial from Aetna Life
Insurance Company (Aetna). The notice will explain the reason for the denial and the appeal procedures
available under the Plan.
Urgent Care Claims
An Urgent Care Claim is any claim for medical care or treatment for which the application of the time
periods for making non-urgent care determinations could seriously jeopardize your life or health or your
ability to regain maximum function, or, in the opinion of a physician with knowledge of your medical
condition, would subject you to severe pain that cannot be adequately managed without the care or
treatment that is the subject of the claim.
If the Plan requires advance approval of a service, supply or procedure before a benefit will be payable,
and if Aetna or your physician determines that it is an Urgent Care Claim, you will be notified of the
decision, whether adverse or not, as soon as possible but not later than 24 hours after the claim is
received.
If there is not sufficient information to decide the claim, you will be notified of the information necessary to
complete the claim as soon as possible, but not later than 24 hours after receipt of the claim. You will be
given a reasonable additional amount of time, but not less than 48 hours, to provide the information, and
you will be notified of the decision not later than 48 hours after the end of that additional time period (or
after receipt of the information, if earlier).
OTHER CLAIMS (PRE-SERVICE AND POST-SERVICE)
If the Plan requires you to obtain advance approval of a non-urgent service, supply or procedure before a
benefit will be payable, a request for advance approval is considered a pre-service claim. You will be
notified of the decision not later than 15 days after receipt of the pre-service claim.
For other claims (post-service claims), you will be notified of the decision not later than 30 days after
receipt of the claim.
For either a pre-service or a post-service claim, these time periods may be extended up to an additional
15 days due to circumstances outside Aetna’s control. In that case, you will be notified of the extension
before the end of the initial 15 or 30-day period. For example, they may be extended because you have
32

not submitted sufficient information, in which case you will be notified of the specific information
necessary and given an additional period of at least 45 days after receiving the notice to furnish that
information. You will be notified of Aetna’s claim decision no later than 15 days after the end of that
additional period (or after receipt of the information, if earlier).
For pre-service claims which name a specific claimant, medical condition, and service or supply for which
approval is requested, and which are submitted to an Aetna representative responsible for handling
benefit matters, but which otherwise fail to follow the Plan's procedures for filing pre-service claims, you
will be notified of the failure within five days (within 24 hours in the case of an urgent care claim) and of
the proper procedures to be followed. The notice may be oral unless you request written notification.
Ongoing Course of Treatment
If you have received pre-authorization for an ongoing course of treatment, you will be notified in advance
if the previously authorized course of treatment is intended to be terminated or reduced so that you will
have an opportunity to appeal any decision to Aetna and receive a decision on that appeal before the
termination or reduction takes effect. If the course of treatment involves urgent care, and you request an
extension of the course of treatment at least 24 hours before its expiration, you will be notified of the
decision within 24 hours after receipt of the request.
HEALTH CLAIMS: STANDARD APPEALS
As an individual enrolled in the Plan, you have the right to file an appeal from an Adverse Benefit
Determination relating to service(s) you have received or could have received from your health care
provider under the Plan.
An Adverse Benefit Determination is defined as a denial, reduction, termination of, or failure to, provide or
make payment (in whole or in part) for a service, supply or benefit. Such Adverse Benefit Determination
may be based on:
• Your eligibility for coverage, including a retrospective termination of coverage (whether or not there is
an adverse effect on any particular benefit);
• Coverage determinations, including plan limitations or exclusions;
• The results of any Utilization Review activities;
• A decision that the service or supply is experimental or investigational; or
• A decision that the service or supply is not Medically Necessary.
A Final Internal Adverse Benefit Determination is defined as an Adverse Benefit Determination that has
been upheld by the appropriate named fiduciary (Aetna) at the completion of the internal appeals
process, or an Adverse Benefit Determination for which the internal appeals process has been
exhausted.
EXHAUSTION OF INTERNAL APPEALS PROCESS
Generally, you are required to complete all appeal processes of the Plan before being able to obtain
External Review or bring an action in litigation. However, if Aetna, or the Plan or its designee, does not
strictly adhere to all claim determination and appeal requirements under applicable federal law, you are
considered to have exhausted the Plan’s appeal requirements (Deemed Exhaustion) and may proceed
with External Review or may pursue any available remedies under §502(a) of ERISA or under state law,
as applicable.
FULL AND FAIR REVIEW OF CLAIM DETERMINATIONS AND APPEALS
Aetna will provide you, free of charge, with any new or additional evidence considered, relied upon, or
generated by Aetna (or at the direction of Aetna), or any new or additional rationale as soon as possible
33

and sufficiently in advance of the date on which the notice of Final Internal Adverse Benefit Determination
is provided, to give you a reasonable opportunity to respond prior to that date.
You may file an appeal in writing to Aetna at the address provided in this booklet, or, if your appeal is of
an urgent nature, you may call Aetna’s Member Services Unit at the toll-free phone number on your ID
card. Your request should include the group name (that is, your employer), your name, member ID, or
other identifying information shown on the front of the Explanation of Benefits form, and any other
comments, documents, records and other information you would like to have considered, whether or not
submitted in connection with the initial claim.
An Aetna representative may call you or your health care provider to obtain medical records and/or other
pertinent information in order to respond to your appeal.
You will have 180 days following receipt of an Adverse Benefit Determination to appeal the determination
to Aetna. You will be notified of the decision not later than 15 days (for pre-service claims) or 30 days (for
post-service claims) after the appeal is received. You may submit written comments, documents, records
and other information relating to your claim, whether or not the comments, documents, records or other
information were submitted in connection with the initial claim. A copy of the specific rule, guideline or
protocol relied upon in the Adverse Benefit Determination will be provided free of charge upon request by
you or your Authorized Representative. You may also request that Aetna provide you, free of charge,
copies of all documents, records and other information relevant to the claim.
If your claim involves urgent care, an expedited appeal may be initiated by a telephone call to the phone
number included in your denial, or to Aetna's Member Services. Aetna's Member Services telephone
number is on your Identification Card. You or your Authorized Representative may appeal urgent care
claim denials either orally or in writing. All necessary information, including the appeal decision, will be
communicated between you or your Authorized Representative and Aetna by telephone, facsimile, or
other similar method. You will be notified of the decision not later than 36 hours after the appeal is
received.
If you are dissatisfied with the appeal decision on an urgent care claim, you may file a second level
appeal with Aetna. You will be notified of the decision not later than 36 hours after the appeal is received.
If you are dissatisfied with a pre-service or post-service appeal decision, you may file a second level
appeal with Aetna within 60 days of receipt of the level one appeal decision. Aetna will notify you of the
decision not later than 15 days (for pre-service claims) or 30 days (for post-service claims) after the
appeal is received.
If you do not agree with the Final Internal Adverse Benefit Determination on review, you have the right to
bring a civil action under Section 502(a) of ERISA, if applicable.
HEALTH CLAIMS: VOLUNTARY APPEALS
EXTERNAL REVIEW
External Review is a review of an Adverse Benefit Determination or a Final Internal Adverse Benefit
Determination by an Independent Review Organization/External Review Organization (ERO) or by the
State Insurance Commissioner, if applicable.
A Final External Review Decision is a determination by an ERO at the conclusion of an External Review.
You must complete all of the levels of standard appeal described above before you can request External
Review, other than in a case of Deemed Exhaustion. Subject to verification procedures that the Plan may
establish, your Authorized Representative may act on your behalf in filing and pursuing this voluntary
appeal.
You may file a voluntary appeal for External Review of any Adverse Benefit Determination or any Final
Internal Adverse Benefit Determination that qualifies as set forth below.
34

The notice of Adverse Benefit Determination or Final Internal Adverse Benefit Determination that you
receive from Aetna will describe the process to follow if you wish to pursue an External Review, and will
include a copy of the Request for External Review Form.
You must submit the Request for External Review Form to Aetna within 123 calendar days of the date
you received the Adverse Benefit Determination or Final Internal Adverse Benefit Determination notice. If
the last filing date would fall on a Saturday, Sunday or Federal holiday, the last filing date is extended to
the next day that is not a Saturday, Sunday or Federal holiday. You also must include a copy of the notice
and all other pertinent information that supports your request.
If you file a voluntary appeal, any applicable statute of limitations will be tolled while the appeal is
pending. The filing of a claim will have no effect on your rights to any other benefits under the Plan.
However, the appeal is voluntary and you are not required to undertake it before pursuing legal action.
If you choose not to file for voluntary review, the Plan will not assert that you have failed to exhaust your
administrative remedies because of that choice.
REQUEST FOR EXTERNAL REVIEW
The External Review process under this Plan gives you the opportunity to receive review of an Adverse
Benefit Determination (including a Final Internal Adverse Benefit Determination) conducted pursuant to
applicable law. Your request will be eligible for External Review if the following are satisfied:
• Aetna, or the Plan or its designee, does not strictly adhere to all claim determination and appeal
requirements under federal law; or
• the standard levels of appeal have been exhausted; or
• the appeal relates to a rescission, defined as a cancellation or discontinuance of coverage which has
retroactive effect.
An Adverse Benefit Determination based upon your eligibility is not eligible for External Review.
If upon the final standard level of appeal, the coverage denial is upheld and it is determined that
you are eligible for External Review, you will be informed in writing of the steps necessary to
request an External Review.
An independent review organization refers the case for review by a neutral, independent clinical reviewer
with appropriate expertise in the area in question. The decision of the independent external expert
reviewer is binding on you, Aetna and the Plan unless otherwise allowed by law.
PRELIMINARY REVIEW
Within five business days following the date of receipt of the request, Aetna must provide a preliminary
review determining: you were covered under the Plan at the time the service was requested or provided,
the determination does not relate to eligibility, you have exhausted the internal appeals process (unless
Deemed Exhaustion applies), and you have provided all paperwork necessary to complete the External
Review.
Within one business day after completion of the preliminary review, Aetna must issue to you a notification
in writing. If the request is complete but not eligible for External Review, such notification will include the
reasons for its ineligibility and contact information for the Employee Benefits Security Administration (tollfree
number 866-444-EBSA (3272)). If the request is not complete, such notification will describe the
information or materials needed to make the request complete and Aetna must allow you to perfect the
request for External Review within the 123 calendar days filing period or within the 48 hour period
following the receipt of the notification, whichever is later.
35

REFERRAL TO ERO
Aetna will assign an ERO accredited as required under federal law, to conduct the External Review. The
assigned ERO will timely notify you in writing of the request’s eligibility and acceptance for External
Review, and will provide an opportunity for you to submit in writing within 10 business days following the
date of receipt, additional information that the ERO must consider when conducting the External Review.
Within one (1) business day after making the decision, the ERO must notify you, Aetna and the Plan.
The ERO will review all of the information and documents timely received. In reaching a decision, the
assigned ERO will review the claim and not be bound by any decisions or conclusions reached during the
Plan’s internal claims and appeals process. In addition to the documents and information provided, the
assigned ERO, to the extent the information or documents are available and the ERO considers them
appropriate, will consider the following in reaching a decision:
(i) Your medical records;
(ii) The attending health care professional's recommendation;
(iii) Reports from appropriate health care professionals and other documents submitted by the Plan or
issuer, you, or your treating provider;
(iv) The terms of your Plan to ensure that the ERO's decision is not contrary to the terms of the Plan,
unless the terms are inconsistent with applicable law;
(v) Appropriate practice guidelines, which must include applicable evidence-based standards and may
include any other practice guidelines developed by the Federal government, national or professional
medical societies, boards, and associations;
(vi) Any applicable clinical review criteria developed and used by Aetna, unless the criteria are
inconsistent with the terms of the Plan or with applicable law; and
(vii) The opinion of the ERO's clinical reviewer or reviewers after considering the information described in
this notice to the extent the information or documents are available and the clinical reviewer or
reviewers consider appropriate.
The assigned ERO must provide written notice of the Final External Review Decision within 45 days after
the ERO receives the request for the External Review. The ERO must deliver the notice of Final External
Review Decision to you, Aetna and the Plan.
After a Final External Review Decision, the ERO must maintain records of all claims and notices
associated with the External Review process for six years. An ERO must make such records available for
examination by the claimant, Plan, or State or Federal oversight agency upon request, except where such
disclosure would violate State or Federal privacy laws.
Upon receipt of a notice of a Final External Review Decision reversing the Adverse Benefit Determination
or Final Internal Adverse Benefit Determination, the Plan immediately must provide coverage or payment
(including immediately authorizing or immediately paying benefits) for the claim.
EXPEDITED EXTERNAL REVIEW
The Plan must allow you to request an expedited External Review at the time you receive:
a) An Adverse Benefit Determination if the Adverse Benefit Determination involves a medical condition
for which the timeframe for completion of an expedited internal appeal would seriously jeopardize
your life or health or would jeopardize your ability to regain maximum function and you have filed a
request for an expedited internal appeal; or
b) A Final Internal Adverse Benefit Determination, if you have a medical condition where the timeframe
for completion of a standard External Review would seriously jeopardize your life or health or would
jeopardize your ability to regain maximum function, or if the Final Internal Adverse Benefit
36

Determination concerns an admission, availability of care, continued stay, or health care item or
service for which you received emergency services, but have not been discharged from a facility.
Immediately upon receipt of the request for expedited External Review, Aetna will determine whether the
request meets the reviewability requirements set forth above for standard External Review. Aetna must
immediately send you a notice of its eligibility determination.
REFERRAL OF EXPEDITED REVIEW TO ERO
Upon a determination that a request is eligible for External Review following preliminary review, Aetna will
assign an ERO. The ERO shall render a decision as expeditiously as your medical condition or
circumstances require, but in no event more than 72 hours after the ERO receives the request for an
expedited External Review. If the notice is not in writing, within 48 hours after the date of providing that
notice, the assigned ERO must provide written confirmation of the decision to you, Aetna and the Plan.
LEGAL ACTION
No legal action can be brought to recover any benefit under the Plan after three years from the date you
have exhausted the Plan’s review procedure.
SUBROGATION AND RIGHT OF REIMBURSEMENT
1) Subrogation. The Plan does not cover expenses for which another party may be responsible as a
result of having caused or contributed to an Injury, Illness or other loss. This means that, to the extent
the Plan provides or pays benefits or expenses for Covered Services, you automatically assign to the
Plan and the Plan assumes your (and your heirs’, estate’s or legal representative’s) legal rights to
recover the amount of those benefits or expenses from any person, entity, organization or insurer,
including, but not limited to, your own insurer and any under insured or uninsured coverage, that may
be legally obligated to pay for those benefits or expenses. This process is referred to as subrogation.
The amount of the Plan’s subrogation rights shall equal the full amount you are entitled to receive up
to the total amount paid by the Plan for the benefits or expenses for Covered Services.
The Plan’s right of subrogation applies on a first-dollar basis and shall have priority over your or
anyone else’s rights until the Plan recovers the total amount the Plan paid for Covered Services. The
Plan’s right of subrogation for the total amount the Plan paid for Covered Services is absolute and
applies whether or not you receive, or are entitled to receive, a full or partial recovery or whether or
not you are “made whole” by reason of any recovery from any other person or entity, and applies to
funds paid for any reason, including non-medical or dental charges, attorney fees, or other costs and
expenses. This provision is intended to and does reject and supersede the “make-whole” rule, which
rule might otherwise require that you be “made whole” before the Plan may be entitled to assert its
right of subrogation.
The Plan’s right of subrogation allows the Plan to pursue any claim, right or cause of action that you (and
your heirs, estate or legal representative) may have, whether or not you (or your heirs, estate or legal
representative) chooses to pursue that claim. You must cooperate with the Plan Administrator and
Employer in any respect necessary or advisable to make, perfect or prosecute such claim, right or
cause of action, and shall enter into a subrogation agreement with the Plan upon the request of the
Plan Administrator or Employer. By this assignment, the Plan’s right to recover from insurers includes,
without limitation, such recovery rights against no-fault auto insurance carriers in a situation where no
third party may be liable.
2) Reimbursement. The Plan also reserves the right of reimbursement. This means that, to the extent
the Plan provides or pays benefits or expenses for Covered Services, you must repay the Plan from,
and the Plan has the right to reimbursement from, any amounts recovered by suit, claim, settlement
or otherwise, from any person, entity, organization or insurer, including your own insurer and any
under insured or uninsured motorist coverage, for those benefits or expenses (even if the amounts
recovered are not designated as payments of medical expenses). The amount of the Plan’s
37

eimbursement rights shall equal the full amount you receive up to the total amount paid by the Plan
for the benefits or expenses for Covered Services.
The Plan’s right of reimbursement applies on a first-dollar basis and shall have priority over your or
anyone else’s rights until the Plan recovers the total amount the Plan paid for Covered Services. The
Plan’s right of reimbursement for the total amount the Plan paid for Covered Services is absolute and
applies whether or not you receive, or are entitled to receive, a full or partial recovery or whether or
not you are “made whole” by reason of any recovery from any other person or entity, and applies to
funds paid for any reason, including non-medical or dental charges, attorney fees, or other costs and
expenses. This provision is intended to and does reject and supersede the “make whole” rule, which
rule might otherwise require that you be “made whole’ before the Plan may be entitled to assert its
right of reimbursement.
By filing a claim for and/or accepting benefits (whether the payment of such benefits is made to you
or made on behalf of you to any Provider) under this Plan, you are deemed to have consented to the
Plan’s right of reimbursement and to have agreed to cooperate with the Plan Administrator and
Employer in any respect necessary or advisable to make, perfect or prosecute such claim, right or
cause of action, and shall enter into a reimbursement agreement with the Plan upon the request of
the Plan Administrator or Employer.
3) Equitable Lien and other Equitable Remedies. The Plan shall have an equitable lien against any
right you may have to recover all or part of the benefits or expenses for Covered Services paid by the
Plan from any party, including an insurer or another group health program, but limited to the total
amount paid by the Plan for the benefits or expenses for Covered Services. The equitable lien also
attaches to any right to payment from workers’ compensation, whether by judgment or settlement,
where the Plan has paid Covered Expenses prior to a determination that the Covered Expenses
arose out of and in the course of employment. Payment by workers’ compensation insurers or the
Employer will be deemed to mean that such a determination has been made.
This equitable lien shall also attach to any money or property that is obtained by anybody (including,
but not limited to, you, your attorney, and/or a trust), whether by judgment, settlement or otherwise,
as a result of an exercise of your rights of recovery for benefits or expenses for Covered Services
paid by the Plan, up to the total amount paid by the Plan for the benefits or expenses for Covered
Services (sometimes referred to as “proceeds”). The lien may be enforced against any party who
possesses proceeds representing an amount paid by the Plan for the benefits or expenses for
Covered Services including, but not limited to, you, your representative or agent; third party; third
party’s insurer, representative, or agent; and/or any other source possessing funds representing an
amount paid by the Plan for the benefits or expenses for Covered Services. The Plan shall also be
entitled to seek any other equitable remedy against any party possessing or controlling such
proceeds. At the discretion of the Plan Administrator, the Plan may reduce any future Covered
Expenses otherwise available to you under the Plan by an amount up to the total amount paid by the
Plan for the benefits or expenses for Covered Services that is subject to the equitable lien.
This and any other provisions of the Plan concerning equitable liens and other equitable remedies are
intended to meet the standards for enforcement under ERISA that were enunciated in the United States
Supreme Court’s decisions entitled, Great-West Life & Annuity Insurance Co. v. Knudson, 534 U.S., 204
(1/8/2002); and Sereboff v. Mid Atlantic Medical Services, Inc., 126 Sup. Ct. 1869 (2006). The provisions
of the Plan concerning subrogation, equitable liens and other equitable remedies are also intended to
supersede the applicability of the federal common law doctrine commonly referred to as the “common
fund” rule.
By accepting benefits (whether the payment of such benefits is made to you or made on behalf of you
to any Provider) from the Plan, you agree that if you receives any payment from any third party as a
result of an Injury, Illness, or condition for which benefits are paid by the Plan, you will serve as a
constructive trustee over the funds that constitutes such payment. Failure to hold such funds in trust
will be deemed a breach of your fiduciary duty to the Plan.
38

4) Assisting in Plan’s Reimbursement Activities. You have an obligation to assist the Plan in obtaining
reimbursement of the total amount paid on your behalf for the benefits or expenses for Covered
Services, and to provide the Plan with any information concerning your other insurance coverage
(whether through automobile insurance, other group health program, or otherwise) and any other person
or entity (including your insurer(s)) that may be obligated to provide payments or benefits to you or for
your benefit. You are required to (a) notify the Plan Administrator within 30 days of the date when any
notice is given to any party, including an insurance company or attorney, of your intention to pursue or
investigate a claim to recover damages or obtain compensation due to Injury, Illness, or a condition
sustained by you, (b) cooperate fully in the Plan’s exercise of its rights to subrogation and
reimbursement, (c) not do anything to prejudice those rights (such as settling a claim against another
party without including the Plan as a co-payee for the total amount paid on your behalf for the benefits
or expenses for Covered Services and notifying the Plan) or to prejudice the Plan’s ability to enforce
the terms of this provision, (d) sign any document deemed by the Plan Administrator to be relevant to
protecting the Plan’s subrogation, reimbursement or other rights, and (e) provide relevant information
when requested. The term “information” includes any documents, insurance policies, police reports, or
any reasonable request by the Plan Administrator to enforce the Plan’s rights. Failure to provide
requested information may result in the termination of your coverage under the Plan or the institution
of court proceeding against you.
5) Overpayments. If a benefit payment is made to or on behalf of any person that exceeds the benefit
amount such person is entitled to receive in accordance with the terms of the Plan, this Plan has the
right:
• To require the return of the overpayment on request; or
• To reduce, by the amount of the overpayment, any future benefit payment made to or on behalf of
that person or another person in his or her family.
This provision does not affect any other right of recovery the Plan may have with respect to
overpayments.
Your failure to follow the above terms and conditions may result, at the discretion of the Plan
Administrator, in a reduction from future benefit payments available to you under the Plan of an amount
up to the aggregate amount paid on your behalf for the benefits or expenses for Covered Services that
has not been reimbursed to the Plan.
In the event that any claim is made that any part of this subrogation and reimbursement provision is
ambiguous or questions arise concerning the meaning or intent of any of its terms, the Plan Administrator
or its delegate shall have the sole authority and discretion to resolve all disputes regarding the
interpretation of this provision.
By accepting benefits (whether the payment of such benefits is made to you or made on behalf of you to
any Provider) from the Plan, you agree that any court proceeding with respect to this provision may be
brought in any court of competent jurisdiction as the Plan may elect. By accepting such benefits, you
hereby submit to each such jurisdiction, waiving whatever rights may correspond to you by reason of your
present or future domicile.
AMENDMENT OR TERMINATION OF THE PLAN
Trinity Health intends to continue this Plan indefinitely. However, certain circumstances may require that
this Plan be amended or terminated. Trinity Health expressly reserves the right to amend, modify, or
terminate this Plan at any time in its sole discretion by action of a duly Authorized Representative.
In the event that any such action results in the termination of coverage, benefits will only be paid for
claims incurred prior to the date of termination of coverage.
39

STATE OF MICHIGAN DISCLOSURE REQUIREMENT
The Plan is a self-funded plan. Covered Individuals in this Plan are not insured. In the event this Plan does
not ultimately pay expenses that are eligible for payment under this Plan for any reason, the individuals
covered by this Plan may be liable for those expenses.
The Medical Claims Administrator, Aetna, merely processes claims and does not insure that any medical
expenses of individuals covered by this Plan will be paid.
Complete and proper claims for benefits made by Covered Individuals will be promptly processed. In the
event of a delay in processing, the Covered Individual shall have no greater right or interest or other remedy
against the Medical Claims Administrator than as otherwise afforded by law.
40

EMPLOYEE RETIREMENT INCOME SECURITY ACT OF
1974 (ERISA) STATEMENT OF PARTICIPANT RIGHTS
As a participant in the Plan, you are entitled to certain rights and protections under the Employee
Retirement Income Security Act of 1974, as amended (“ERISA”). ERISA provides that all Plan
participants shall be entitled to:
RECEIVE INFORMATION ABOUT YOUR PLAN AND BENEFITS
• Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as
worksites and union halls, all documents governing the Plan, including insurance contracts and
collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by
the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the
Employee Benefits Security Administration.
• Obtain, upon written request to the Plan Administrator, copies of documents governing the operation
of the Plan, including insurance contracts and collective bargaining agreements, and copies of the
latest annual report (Form 5500 Series) and updated Summary Plan Description. The Plan
Administrator may make a Reasonable Charge for the copies.
• Receive a summary of the Plan’s annual financial report. The Plan Administrator is required to furnish
each participant with a copy of this summary annual report.
CONTINUE GROUP HEALTH PLAN COVERAGE
• Continue health care coverage for yourself, spouse or other Dependents if there is a loss of coverage
under the Plan as a result of a qualifying event. You or your Dependents may have to pay for such
coverage. Review this Summary Plan Description and the documents governing the Plan on the rules
governing your COBRA continuation coverage rights.
• Reduction or elimination of exclusionary periods of coverage for preexisting conditions under the
Plan, if you have creditable coverage from another plan. You should be provided a certificate of
creditable coverage, free of charge, from the Plan or health insurance issuer when you lose coverage
under the Plan, when you become entitled to elect COBRA continuation coverage, when your
COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up
to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a
preexisting condition exclusion for 12 months (18 months for Late Enrollees) after your enrollment
date in your coverage.
PRUDENT ACTION BY PLAN FIDUCIARIES
In addition to creating rights for Plan participants ERISA imposes duties upon the people who are
responsible for the operation of the employee benefit plan. The people who operate your Plan, called
“fiduciaries” of the plan, have a duty to do so prudently and in the interest of you and other Plan
participants and beneficiaries. No one, including your employer, your union, or any other person, may fire
you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or
exercising your rights under ERISA.
ENFORCE YOUR RIGHTS
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have the right to know why
this was done, to obtain documents relating to the decision without charge, and to appeal any denial, all
within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a
copy of Plan documents or the latest annual report from the Plan and do not receive them within 30 days,
41

you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to
provide the materials and pay you up to $110 a day until you receive the materials, unless the materials
were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for
benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In
addition, if you disagree with the Plan’s decision or lack thereof concerning the qualified status of a
domestic relations order or medical child support order, you may file suit in Federal court. If it should
happen that Plan fiduciaries misuse the Plan’s money, of if you are discriminated against for asserting
your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal
court. The court will decide who should pay court costs and legal fees. If you are successful, the court
may order the person you have sued to pay these costs and fees. If you lose, the court may order you to
pay these costs and fees, for example, if it finds your claim is frivolous.
ASSISTANCE WITH YOUR QUESTIONS
If you have any questions about your Plan, you should contact the Plan Administrator. If you have any
questions about this statement or about your rights under ERISA, or if you need assistance in obtaining
documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits
Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of
Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of
Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications
about your rights and responsibilities under ERISA by calling the publications hotline of the Employee
Benefits Security Administration.
42

IMPORTANT INFORMATION ABOUT THE PLAN
Plan Sponsor Trinity Health
34605 Twelve Mile Road
Farmington Hills, MI 48331
Name of Plan and
Type of Plan
Plan Number 504
Employer Identification Number: 35-1443425
Phone Number: 248-324-8117
The Medical Program under component Plan 504 of the Trinity Health
Welfare Benefit Plan
This Plan is a welfare benefits plan providing medical benefits.
Plan Year The Plan Year begins on January 1st and ends on December 31st, and Plan
records are maintained on that basis.
Plan
Administrator and
Named Fiduciary
Type of Administration
and Fund
The Plan Administrator, named fiduciary and agent for service of legal
process is:
Trinity Health
34605 Twelve Mile Road
Farmington Hills, MI 48331
Benefits under the Plan are self-insured. The following entity is responsible
for the day-to-day administration of the Plan (Aetna PPO Health Care Plan
option) described in this SPD, including claims processing:
Aetna Life Insurance Company
151 Farmington Avenue
Hartford, CT 06156
The Aetna PPO health care plan option was effective as of January 1, 2008.
Cost of the Plan You and your Employer share the cost of providing Plan benefits for you and
your eligible Dependents.
Request for Plan
Information
The Plan is funded through the general assets of the Employer. In the event of
Plan termination, there are no specific assets set aside to use to pay claims
incurred prior to the date of such termination. If the Plan should be terminated,
only claims incurred prior to the date of such termination would be paid by the
Plan.
Requests to review Plan documents, requests for copies of Plan documents,
and questions regarding Plan operations should be directed to Plan
Administrator at the address and telephone number provided above.
43

HOW SERVICES ARE PAID THROUGH THE PLAN
Both you and the Employer pay a portion of the total cost for your health care coverage. This is called
“cost sharing.” The total cost of your health care coverage includes payroll contributions, Copayments,
Coinsurance amounts, Deductibles, claim costs, and administrative fees. Here is an explanation of how
your health care coverage is paid.
1) When you elect coverage under the Plan, you pay for your coverage through payroll contributions.
The amount of your contributions is based on the level of coverage you choose.
2) When you receive health care services, you must first meet the annual Deductible before the Plan
starts to pay its portion of the expenses. The amount of the Deductible is based on your coverage
level. Keep in mind, there is a Deductible for Covered Expenses and a separate Deductible for
covered Prescription Drug expenses.
3) Once you have met the annual Deductible, you will pay a Copayment or Coinsurance amount for your
health care services. A Copayment is a fixed flat-dollar amount you pay. The Plan pays the remaining
amount. When you pay Coinsurance, you pay a percentage of the expense and the Plan pays the
remaining percentage.
4) You will continue to pay Copayment or Coinsurance amounts for covered services until you meet the
Out-of-Pocket Maximum. The Out-of-Pocket Maximum is the most you will pay for covered expenses
during a Plan Year. Once you meet the Out-of-Pocket Maximum (based on your coverage level) the
Plan will pay the remaining expenses for that Plan Year. You should note, certain expenses do not
count toward the Out-of-Pocket Maximum and are listed below.
The following amounts not counted toward the Out-of-Pocket Maximum expense limit and, therefore, not
eligible for 100 percent payment even if the Out-of-Pocket Maximum expense limit is met:
• Copayments
• Deductibles
• Amounts over the usual, customary, and Reasonable Charges (UCR)
• Applicable Penalties
• Coinsurance or Copayments for Prescription Drugs
• Office visit Copayments
• Hospital Inpatient Copayments
• Coinsurance for services related to Temporomandibular Joint Syndrome
• Coinsurance for infertility drugs
Expenses applied toward the non-Network Out-of-Pocket Maximum will be used to satisfy the Network Outof-Pocket
Maximum, and expenses applied to the Network Out-of-Pocket Maximum will be applied to the
non-Network Out-of-Pocket Maximum.
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COVERED MEDICAL EXPENSES
The Plan provides coverage for most Medically Necessary services, procedures and supplies. Most
specific services that are not covered are listed in this Booklet.
The Plan is designed to provide levels of benefits based on the choices you make. By choosing the
services of a Trinity Health Facility or a Network provider, you will receive a higher level of payment.
Detailed information about how benefits will be paid can be found in the Benefits Summary.
HOW WILL YOU BENEFIT FROM CHOOSING A NETWORK PROVIDER?
The Plan has contracted with certain physician and hospital providers to be the Plan's Network providers.
The Plan, Aetna, the Employer, and the Plan Administrator do not provide any guarantee concerning the
care provided by Network providers. Copies of the PPO provider directories can be obtained, at no
charge, from the Human Resources / Organization and Talent Effectiveness http://mybenefits.trinityhealth.org/columbus/2008.shtml.
You, together with your physician, are ultimately responsible for determining the appropriate treatment
regardless of coverage by this Plan.
WHAT HAPPENS IF YOU ARE NOT ABLE TO USE A NETWORK PROVIDER?
When you or your covered Dependent(s) choose to receive covered services or supplies from a Network
provider, the Plan will pay as described in the Benefits Summary.
NOTE: If a Network physician or facility cannot perform a course of treatment or procedure, you must
obtain an approved referral prior to receiving services by a Non-Network physician or facility. In order to
complete this process, you must contact Aetna at 1-800-544-5108. Whenever possible, a referral to a
Trinity Health approved physician or facility will be provided. When that is not possible, your doctor may
provide a referral to a Non-Network physician or facility. Please remember that the referral must be
obtained prior to receiving the services from a Non-Network physician or facility. Failure to obtain an
approved referral prior to receiving services will result in no benefits being paid. Please refer to the
Benefits Summary for further information.
If you and your covered Dependents reside in an area where Network providers are not available, the
Plan will pay benefits at the Network level when services have been referred in accordance with the
above.
If you or your covered Dependents need emergency treatment for an accidental bodily injury or a lifethreatening
medical emergency and seek treatment (via car or ambulance) at the nearest facility that is
not a Trinity Health facility or Network provider, the Plan will pay benefits at the Network level.
If a covered service, supply, course of treatment or procedure cannot be performed by a Trinity Health
facility or a Network provider; the Plan will pay benefits at the Network level (with approved referral). Any
related laboratory tests, x-rays or follow-up visits by the same Non-Network provider will be paid at the
Network level. It is your responsibility to investigate the availability of a needed provider.
If you seek or are referred for services from a Non-Network provider and such specialty provider and/or
covered service, supply, course of treatment or procedure can be performed by a Network provider, the
Plan will pay benefits at the Non-Network level. Any related laboratory tests, x-rays or follow-up visits by
the same Non-Network provider will be paid at the Non-Network level. It is your responsibility to
investigate the availability of a needed provider.
If you or your covered Dependents use a Trinity Health or a Network facility for inpatient/outpatient
services/procedures, but the Trinity Health or a Network facility uses a Non-Network provider for
anesthesia, the interpretation of laboratory tests and x-rays and other Medically Necessary services, the
Plan will pay benefits at the Network level.
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If you or your covered Dependents are admitted to a Non-Network hospital through the emergency room,
the Plan will pay benefits for that confinement at the Network level until you are stable. At that point, the
Plan will pay benefits at the Non-Network level, unless you are transferred to a Trinity Health or Network
facility.
WHAT IS THE PLAN DEDUCTIBLE?
The Plan considers the Network allowable rate for Medically Necessary services and supplies.
Services that are covered by the Plan are payable after the annual Deductible has been satisfied. Please
see the Benefits Summary for detailed information regarding the Deductible amount.
The Deductible is satisfied on a calendar year basis with expenses from January through December. Any
expense applied toward the Deductible during the last three months of the calendar year may be applied
towards the Deductible for the following year.
When an individual's coverage becomes effective during a calendar year, the Deductible will apply only to
expenses that are incurred after the coverage effective date.
Network Copays and prescription drug Copays cannot be used to satisfy the Plan’s calendar year
Deductible.
WHAT IS YOUR OUT-OF-POCKET MAXIMUM EXPENSE?
This Plan shares with you the expense for certain services. Your Coinsurance is the balance that you
must pay of the covered charge for covered benefits when plan payment is at a percentage other than
100percent.
This plan is designed to limit your out-of-pocket. The out-of-pocket maximum expense limits are for
Covered Services rendered during each calendar year.
The out-of-pocket maximum expense varies depending on the option chosen. Please see the Benefits
Summary for detailed information regarding your out-of-pocket maximum amount.
For services rendered during the remainder of the calendar year after a Covered Individual or family
reaches their out-of-pocket maximum expense limit, this plan will pay 100percent of the reasonable and
customary allowance for subsequent expenses.
Expenses that are not included in the out-of-pocket maximum limit and are not eligible for 100 percent
payment even if the out-of-pocket maximum limit is met are:
• Deductibles
• Amounts over the usual, customary, and reasonable charges (UCR)
• Applicable Penalties
• Charges for services rendered without required referral
• Coinsurance or copayments for prescription drugs
• Plan Copays (including, but not limited to, office visit Copays, Hospital Inpatient Copays, etc.)
• Coinsurance for services related to Temporomandibular Joint Syndrome
HEALTH MANAGEMENT SERVICES
The services outlined in this section of the Plan are part of Aetna Health Management Services.
Together, they ensure that you receive high quality, cost-effective care.
It is important to remember that this Plan covers only those procedures, services, and supplies that are
Medically Necessary unless otherwise specified. For a service to be covered it must be considered
46

necessary for the diagnosis or treatment of an Illness or Injury and the care must be given at the
appropriate level. In determining questions of reasonableness and necessity, consideration is given to the
customary practices of Physicians in the community where the service is provided.
Services, which are NOT considered to be Medically Necessary, include, but are not limited to:
• Procedures of unproven value or of questionable current usefulness
• Procedures, which could be unnecessary when, performed in combination with other procedures
• Diagnostic procedures, which are unlikely to provide a Physician with additional information when
used repeatedly
• Procedures which are not ordered by a Physician or which are not documented in a timely fashion in
the patient’s medical record, or which can be performed with equal effectiveness at a lower level of
care facility (e.g., on an outpatient basis).
For example, a medically unnecessary Hospital admission would be one, which does not require acute
Hospital bed patient care and could have been provided in a Physician’s office, Hospital Outpatient
department, or lower level of care facility without reduction in the quality of care provided and without
harm to the patient. Also, a Hospital admission primarily for observation, evaluation, or diagnostic study,
which could be provided adequately and safely on an outpatient basis is considered to be medically
unnecessary.
CASE MANAGEMENT
Case management is a service designed to develop a quality plan of care. Aetna nurses and other
clinicians will partner with you and your Physician to coordinate your care. They will ensure that you
receive high quality, cost-effective care by accessing your condition, evaluating your needs, and
monitoring your progress.
If you are diagnosed with a serious Illness or suffer a serious Injury, an Aetna nurse will review your
treatment plan with your Physician, and will clarify questions that you may have regarding your treatment.
You can contact an Aetna nurse any time you have a question or concern regarding your treatment. The
nurse will provide you with information about the treatment and will assist you in evaluating your options.
When the patient chooses to follow the recommendations made through case management, the Plan
may, at its discretion, cover additional expenses of alternative care and supplies when recommended by
medical case managers.
If the Plan Administrator determines through case management that the treatment plan submitted is
appropriate, then the Plan participant must follow this plan of treatment in order to receive benefits under
this Plan.
PRE-CERTIFICATION OF SERVICES
A Hospital stay can be a serious and expensive part of your course of treatment. This Plan has a special
program, Pre-Certification of Services, to make sure that you are not Hospitalized unnecessarily. If you
are admitted to (or registered as a patient at) a Hospital or a rehabilitation facility, whether for emergency
treatment, elective non-emergency treatment, or maternity care in excess of 48 hours for normal
deliveries or 96 hours for cesarean delivery, you or a member of your family should call AETNA at the
number listed on your medical identification card. The call should be made prior to the elective hospital
admission. It is your responsibility in conjunction with your Physician’s office to obtain Pre-Certification of
Services.
Aetna’s nurse and your admitting Hospital review your Inpatient treatment plan before and during your
Hospitalization. The objective is to help you obtain all the information you need to make informed
decisions. The AETNA nurse:
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• Checks Medical Necessity of the Hospital admission and length of stay against generally accepted
medical standards,
• Suggests alternative treatment settings, if appropriate, and
• Assist with discharge planning.
You will be notified by mail of the approved length of stay. Additional days may be assigned based on
Medical Necessity.
The final decision regarding treatment and Hospitalization is yours. Maximum allowable Plan benefits are
paid as long as these steps are followed prior to any Inpatient Hospitalization.
If you or a covered Dependent are admitted to a hospital for any reason without prior approval:
• Contact Aetna by telephone within two business days of the admission. You, a family member, or
your Physician may make the contact.
MENTAL DISORDERS AND/OR SUBSTANCE ABUSE
In addition, all Inpatient services (including partial Hospitalization), intensive Outpatient services, and
Outpatient psychiatric testing for Mental Disorders and/or substance abuse require pre-certification
through Aetna Behavioral Health. Please note that if pre-certification is not received for these services,
benefits will not be payable. For pre-certification coordination contact:
Aetna, Inc.
P.O. Box 981107
El Paso, TX 79998-1107
800-544-5108
Benefits available under this Plan for the treatment of Mental Disorders and/or substance abuse are
payable as described in Benefits Summary.
EXPLANATION OF SOME IMPORTANT PLAN PROVISIONS
INPATIENT FACILITY COPAY
This is the amount of Inpatient Facility Expenses you pay for each Hospital, each Convalescent Facility, or
each treatment facility confinement of a Covered Individual. The Inpatient Hospital Copay will only be applied
once to all Hospital confinements, regardless of cause, which are separated by less than 90 days.
CALENDAR YEAR DEDUCTIBLE
This is the amount of Covered Expenses you pay each calendar year before benefits are paid. There is a
Calendar Year Deductible that applies to each Covered Individual.
FAMILY DEDUCTIBLE LIMIT
If Covered Expenses incurred in a calendar year by you and your Dependents and applied against the
separate Calendar Year Deductibles equal the Family Deductible Limit, you and your Dependents will be
considered to have met the separate Calendar Year Deductibles for the rest of that calendar year.
HOSPITAL EMERGENCY ROOM COPAY
A separate Hospital Emergency Room Copay applies to each visit for emergency room care, by a Covered
Individual to a Hospital's emergency room, unless the Covered Individual is admitted to the Hospital as an
Inpatient immediately following a visit to a Hospital emergency room.
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URGENT CARE COPAY
A separate Urgent Care Copay applies to each visit for urgent care by a person to an Urgent Care Provider
unless the person is admitted to the Hospital as an Inpatient immediately following a visit to an Urgent Care
Provider.
GENETIC TESTING/SCREENING AND COUNSELING
Genetic testing/screening is done to look for abnormalities in a person’s genes, or the presence/absence
of key proteins whose production is directed by specific genes.
Please refer to the Benefits Summary for additional information.
Covered Individuals must be referred by a Physician to a Genetic Counselor before testing can occur.
You will be asked to sign a consent form before the test is performed. Only one evaluation visit can
initially be approved.
Genetic counseling, testing and/or screening is covered when all of the following conditions are met:
1) Covered Individual is referred by a Physician to a Genetic Counselor before testing
2) Informed written consent is obtained before and after testing/screening
3) The test has been proven valid (regulatory agency approval)
4) Factors exist to justify that a Covered Individual is at increased risk
5) Knowledge of presence or absence of condition would directly affect medical care, where:
a) The disease is treatable or preventable
b) The test results will lead to a marked change in the intensity of surveillance/treatment of that
disease
NOTE: Tests commonly performed on amniotic fluid by a Physician do not require Genetic Counseling.
Genetic Testing/screening is performed:
a) To determine whether a person has a Genetic Disorder caused by a genetic defect,
b) To determine whether a person is a carrier of a Genetic Disorder caused by a genetic
abnormality,
c) To determine a person’s risk of developing a disease,
d) To predict response to therapy,
e) If there is a history of spontaneous abortions,
f) If a Covered Individual gave birth to a child with a Genetic Disorder or chromosomal abnormality,
g) If there is a family history of certain inherited Genetic Disorders, or the Covered Individual has
symptoms of certain inherited Genetic Disorders and requires a diagnosis,
h) For a Dependent child if there is an increased risk of developing a childhood malignancy,
i) For an adopted child(ren), where the family history is unavailable or unknown, for conditions that
manifest themselves during childhood and for which preventive measures or therapy may be
undertaken during childhood.
Genetic Counseling, testing and/or screen may be covered for non-Covered Individuals when BRCA
testing is required to assess the need for Prophylactic Mastectomies or Oophorectomies for a Covered
Individual.
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All of the following criteria must be met:
a) The information is needed to adequately assess risk in the Covered Individual;
b) The information will be used in the immediate care of the Covered Individual;
c) The non-Covered Individual’s plan (if any) will not cover the test (proof required).
Notwithstanding any genetic testing that is covered under the Plan and performed on behalf of a Covered
Individual, the Plan will not discriminate in its health coverage on the basis of genetic information
pursuant to the Genetic Information Nondiscrimination Act of 2008 (“GINA”). The Plan will comply with the
requirements of GINA to the extent applicable.
NOT COVERED:
• Routine, ongoing, or long-term Genetic Counseling
• Genetic testing to determine the paternity of a child
• Genetic testing to determine the sex of a child
• Genetic testing to determine one’s own genetic predisposition
• General population screening for Genetic Disorders (example-cystic fibrosis)
• Prenatal genetic screening undertaken with the intention of aborting the child
• Genetic testing or screening in children or adolescents, except as provided
• Genetic testing/screening for any individual who is not an eligible Associate or Dependent as defined
in the section titled ELIGIBILITY of this Plan
• Genetic testing for:
o Huntington’s Chorea Disease,
o Li-Fraumeni syndrome,
o Melanoma and melanoma-associated syndromes,
o Ataxia Telanglextasaia-associated susceptibilities.
• Surgical procedure and related expenses that are performed as a precautionary measure when there
is no presence of cancer or other disease (e.g., preventative mastectomy)
HOSPITAL EXPENSES
INPATIENT HOSPITAL EXPENSES
Charges made by a Hospital for giving room and board and other Hospital services and supplies to a
Covered Individual who is confined as a full-time Inpatient.
If a private room is used, the daily room and board charge will be covered if the Covered Individual’s
Preferred Care Provider requests the private room; and the request is pre-approved by Aetna.
If the above procedures are not met, any part of the daily room and board charge, which is more than the
Private Room Limit is not covered.
OUTPATIENT HOSPITAL EXPENSES
Charges made by a Hospital for Hospital services and supplies, which are given to a person who is not
confined as a full-time Inpatient.
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OUTPATIENT SURGICAL EXPENSES
Covered Expenses include charges for Outpatient surgical expenses to the extent shown below.
Covered Expenses include charges made:
• In its own behalf by:
o A Surgery center;
o The Outpatient department of a Hospital; or
o An office based surgical facility of a Physician or a Dentist.
• On behalf of a salaried staff Physician by the Outpatient department of a Hospital.
• For Outpatient Services and Supplies furnished in connection with a surgical procedure performed in
the center or in a Hospital. The procedure must meet these tests:
o It is not expected to:
� Result in extensive blood loss;
� Require major or prolonged invasion of a body cavity; or
� Involve any major blood vessels.
o It can safely and adequately be performed only in a Surgery center or in a Hospital or in an office
based surgical facility of a Physician or a Dentist.
o It is not normally performed in the office of a Physician or a Dentist.
OUTPATIENT SERVICES AND SUPPLIES
These are services and supplies furnished by the Surgery center or by a Hospital on the day of the
procedure.
LIMITATIONS
No benefit is paid for charges incurred while the Covered Individual is confined as a full-time Inpatient in a
Hospital.
CONVALESCENT FACILITY EXPENSES
Charges made by a Convalescent Facility for the following services and supplies. They must be furnished
to a person while confined to convalesce from an Illness or Injury. Includes:
• Board and room (this includes charges for services, such as general nursing care, made in
connection with room occupancy. Not included is any charge for daily room and board in a private
room over the Private Room Limit)
• Use of special treatment rooms
• X-ray and lab work
• Physical, occupational or speech therapy
• Oxygen and other gas therapy
• Other medical services usually given by a Convalescent Facility (this does not include private or
special nursing or Physician's services)
• Medical supplies
Benefits will be paid for no longer than the Convalescent Days Maximum during any one calendar year.
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LIMITATIONS TO CONVALESCENT FACILITY EXPENSES
This section does not cover charges made for treatment of:
• Drug addiction
• Chronic brain syndrome
• Alcoholism
• Senility
• Mental retardation
• Any other mental disorder
HOME HEALTH CARE EXPENSES
Home Health Care expenses are covered if:
• The charges are made by a R.N. or L.P.N. or a nursing agency for “skilled nursing services”; or
• The charge is made by a Home Health Care Agency under a Home Health Care plan for care given
to a Covered Individual in his or her home.
The following services are covered as “skilled nursing services:”
• Visiting nursing care by a R.N. or L.P.N. Visiting nursing care means a visit of not more than four
hours for the purpose of performing specific skilled nursing tasks
• Private duty nursing by a R.N. or L.P.N. if the Covered Individual’s condition requires skilled nursing
care and visiting nursing care is not adequate
Home Health Care expenses are charges for:
• Part-time or intermittent care by a R.N. or L.P.N. if an R.N. is not available
• Physical, occupational, and speech therapy
• Part-time or intermittent home health aide services for patient care
• The following to the extent they would have been covered under this Plan if the Covered Individual
had been confined in a Hospital or Convalescent Facility:
o Medical supplies;
o Drugs and medicines prescribed by a Physician; and
o Lab services provided by or for a Home Health Care Agency.
There is a maximum to the number of visits covered in a calendar year for each Covered Individual for
Home Health Care Expenses.
As to skilled nursing care:
• Each visiting nurse shift or private duty nursing shift of four hours or less counts as one visit;
• Each such shift of over four hours but less than eight hours counts as two visits.
As to Home Health Care:
• Each visit by a nurse or therapist is one visit;
• Each visit of up to four hours by a home health aide is one visit.
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LIMITATIONS TO HOME CARE EXPENSES
Covered Expenses for skilled nursing care do not include charges for:
• That part or all of any nursing care that does not require the education, training, and technical skills of
a R.N. or L.P.N.; such as transportation, meal preparation, charting of vital signs and companionship
activities; or
• Any private duty nursing care, given while the Covered Individual is an Inpatient in a Hospital or other
health care facility; or
• Care provided to help a Covered Individual in the activities of daily life; such as bathing, feeding,
personal grooming, dressing, getting in and out of bed or a chair, or toileting; or
• Care provided solely for skilled observation except as follows:
o For no more than one, four hour period per day for a period of no more than 10 consecutive days
following the occurrence of:
� Change in patient medication;
� Need for treatment of an Emergency condition by a Physician, or the onset of symptoms
indicating the likely need for such services;
� Surgery
� Release from Inpatient confinement; or
o Any service provided solely to administer oral medicines; except where applicable law requires
that such medicines be administered by a R.N. or L.P.N.
Covered Expenses for Home Health Care do not include charges for:
• Services or supplies that are not a part of the Home Health Care plan
• Services of a social worker
• That part or all of any nursing care that does not require the education, training and technical skills of
a R.N. or L.P.N.; such as transportation, meal preparation, charting of vital signs, and companionship
activities
PREVENTIVE PHYSICAL EXAM EXPENSES
The charges made by your Primary Care Physician or a Preferred Care Provider for a routine physical
exam given to you, your spouse, or your Dependent child may be included as Covered Expenses. A
routine physical exam is a medical exam given by a Physician for a reason other than to diagnose or treat
a suspected or identified Injury or Illness. Included are:
• X-rays, laboratory and other tests including a Pap Smear given in connection with the exam; and
• Materials for the administration of immunizations for infectious disease and testing for tuberculosis.
FOR A DEPENDENT CHILD:
To qualify as a covered physical exam, the Physician's exam must include at least:
• A review and written record of the Dependent child’s complete medical history;
• A check of all body systems; and
• A review and discussion of the exam results with the Dependent child or with the parent or guardian.
For all exams given to your child under age 17, Covered Expenses will only include charges for:
53

• Seven exams in the first 12 months of life;
• Three exams in the second 12 months of life;
• Three exams in the third 12 months of life; and
• One annual physical examination thereafter.
For all exams given to your child age 18 and over, Covered Expenses will not include charges for more
than one exam per calendar year.
FOR YOU AND YOUR SPOUSE:
For all exams given to you or your spouse, Covered Expenses will not include charges for more than:
• One exam in per calendar year for a person under age 65; and
• One exam in per calendar year for a person age 65 and over.
Also included, as Covered Expenses are charges made by a Physician for one annual routine
gynecological exam. Included, as part of the exam is a routine Pap Smear.
LIMITATIONS TO PREVENTIVE PHYSICAL EXAM EXPENSES
This section does not cover charges for:
• Services which are covered to any extent under any other part of this Plan or any other group plan
sponsored by your Employer;
• Services which are for diagnosis or treatment of a suspected or identified Injury or Illness;
• Exams given while the Covered Individual is confined in a Hospital or other place for medical care;
• Services not given by a Physician or under his or her direction;
• Medicines, drugs, appliances, equipment or supplies;
• Psychiatric, psychological, personality or emotional testing or exams;
• Exams in any way related to employment;
• Premarital exams;
• Vision, hearing or dental exams;
• A Physician's office visit in connection with immunization or testing for tuberculosis; or
• Services and supplies furnished by a Non-Preferred Care Provider.
PREVENTIVE HEARING EXAM EXPENSES
Covered Expenses include charges for an audiometric exam. The services must be performed by:
• A Physician certified as an otolaryngologist or otologist; or
• An audiologist who either:
o Is legally qualified in audiology; or
o Holds a certificate of Clinical Competence in Audiology from the American Speech and Hearing
Association in the absence of any applicable licensing requirements; and
o Who performs the exam at the written direction of a legally qualified otolaryngologist or otologist.
Covered Expenses will only cover charges for one hearing exam in per calendar year.
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Not included are charges for:
• Any ear or hearing exam to diagnose or treat an Illness or Injury;
• Drugs or medicines;
• Any hearing care service or supply which is a Covered Expense in whole or in part under any other
part of this Plan or under any other plan of group benefits provided through your Employer;
• Any hearing care service or supply for which a benefit is provided under any workers' compensation
law or any other law of like purpose, whether benefits are payable as to all or only part of the charges;
• Any hearing care service or supply which does not meet professionally accepted standards;
• Any service or supply received while the person is not a Covered Individual;
• Any exams given while the Covered Individual is confined in a Hospital or other facility for medical
care;
• Any exam required by an employer as a condition of employment, or which an employer is required to
provide under a labor agreement or is required by any law of a government, or
• Any service or supply furnished by a Non-Preferred Care Provider.
HOSPICE CARE EXPENSES
Charges made for the following furnished to a Covered Individual for Hospice Care when given as a part
of a Hospice Care program are included as Covered Medical Expenses.
FACILITY EXPENSES
The charges made in its own behalf by a:
• Hospice Facility;
• Hospital; or
• Convalescent Facility.
Which are for:
INPATIENT CARE
Room and Board and other services and supplies furnished to a Covered Individual while a full-time
Inpatient for: pain control and other acute and chronic symptom management.
• Not included is any charge for daily room and board in a private room over the Private Room Limit.
OUTPATIENT CARE
Services and supplies furnished to a Covered Individual while not confined as a full-time Inpatient.
OTHER EXPENSES FOR OUTPATIENT CARE
Charges made by a Hospice Care Agency for:
• Part-time or intermittent nursing care by an R.N. or L.P.N. for up to eight hours in any one day.
• Medical social services under the direction of a Physician. These include:
o Assessment of the Covered Individual’s:
� Social, emotional, and medical needs; and
55

� The home and family situation;
� Identification of the community resources which are available to the Covered Individual; and
� Assisting the Covered Individual to obtain those resources needed to meet his or her
assessed needs.
• Psychological and dietary counseling.
• Consultation or case management services by a Physician.
• Physical and occupational therapy.
• Part-time or intermittent home health aide services for up to eight hours in any one day (these consist
mainly of caring for the Covered Individual).
• Medical supplies
• Drugs and medicines prescribed by a Physician.
Charges made by the Providers below for Outpatient Care, but only if: the Provider is not an associate of
a Hospice Care Agency; and such Agency retains responsibility for the care of the Covered Individual.
• A Physician for consultant or case management services.
• A physical or occupational therapist.
• A Home Health Care Agency for:
o Physical and occupational therapy;
o Part-time or intermittent home health aide services for up to eight hours in any one day; these
consist mainly of caring for the Covered Individual;
o Medical supplies;
o Drugs and medicines prescribed by a Physician; and
o Psychological and dietary counseling.
Not included are charges made:
• For bereavement counseling
• For funeral arrangements
• For pastoral counseling
• For financial or legal counseling (his includes estate planning and the drafting of a will)
• For homemaker or caretaker services(these are services which are not solely related to care of the
Covered Individual. These include: sitter or Companion services for either the Covered Individual who
is ill or other members of the family; transportation; housecleaning; and maintenance of the house.)
• For respite care in excess of 60 days per calendar year (this is care furnished during a period of time
when the Covered Individual’s family or usual caretaker cannot, or will not, attend to his or her needs)
OUTPATIENT SHORT-TERM REHABILITATION EXPENSE COVERAGE
The charges made by:
• A Physician; or
• A licensed or certified physical, occupational or speech therapist;
for the following services for treatment of acute conditions are Covered Expenses
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Short-term rehabilitation is therapy which is expected to result in the improvement of a body function
which has been lost or impaired due to:
• An Injury;
• An Illness; or
• Congenital defect. (excludes speech therapy)
Short-term rehabilitation services consist of:
• Physical therapy;
• Occupational therapy, or
• Speech therapy
furnished to a Covered Individual who is not confined as an Inpatient in a Hospital or other facility for
medical care. This therapy shall be expected to result in significant improvement of the Covered
Individual’s condition within 60 days from the date the therapy begins.
Not covered are charges for:
• Services which are covered to any extent under any other part of this Plan
• Any services, which are, Covered Expenses in whole or in part under any other group plan sponsored
by an Employer
• Services received while the Covered Individual is confined in a Hospital or other facility for medical
care
• Services not performed by a Physician or under his or her direct supervision
• Services rendered by a physical, occupational, or speech therapist who resides in the Covered
Individual’s home or who is a part of the family of either the Covered Individual or the Covered
Individual's spouse
• Services rendered for the treatment of delays in speech development resulting from:
o Congenital defect unless following surgery
o Learning disability
• Special education, including lessons in sign language, to instruct a Covered Individual whose ability
to speak has been lost or impaired to function without that ability
• Treatment for which a benefit is or would be provided under the Spinal Manipulation Expenses
section, whether or not benefits for the maximum number of visits under that section have been paid
Also, not covered are any services unless they are provided in accordance with a specific treatment plan
which:
• details the treatment to be rendered and the frequency and duration of the treatment
• provides for ongoing reviews and is renewed only if therapy is still necessary
PRESCRIPTION DRUGS
Prescription Drugs that are necessary for the treatment of an Illness or Injury of a Covered Individual when
prescribed by a Physician are covered as described below. Drugs furnished during a Hospital confinement will be
payable as described the Covered Services section of this SPD.
Prescription Drugs purchased in a participating pharmacy are covered by the Prescription Drug benefit
administered by CVS Caremark. The participating pharmacy will fill the prescription with a generic equivalent,
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unless a generic substitute is not available. For each new or refilled prescription, you simply pay the
Copayment or Coinsurance shown in the Benefits Summary. When drugs are purchased at a pharmacy, the
Prescription Drug program will allow up to a 34-day supply. If you need a brand name drug and a generic
equivalent drug is available you will be charged the difference in ingredient cost between the brand and
generic drug, in addition to the brand Copayment.
Maintenance drugs (to treat long-term or chronic medical conditions) can be obtained by mail through a
CVS Caremark Mail Service Pharmacy. This program allows you to save money by receiving a 90-day
supply of medication for a low Copayment or Coinsurance.
COVERED DRUGS
The following are covered drugs unless listed as an exclusion below:
• Federal Legend Drugs
• State Restricted Drugs
• Compounded Medications of which at least one ingredient is a legend drug
• Insulin
• Needles and Syringes
• OTC Diabetic Test Strips and Lancets
• Retin-A through age 25
• Tazorac cream through age 25
• Zostavax *
• Pediatric Fluoride Vitamins*
• Legend Pediatric Fluoride Vitamin Drops up to a 50-day supply
• Inhalers, Assisted Devices
*Age limit may apply under medical or dental benefit
PRIOR AUTHORIZATION REQUIRED
The following drugs are covered only after CVS Caremark receives prior authorization from your Physician:
• Retin-A/Avita/Altinac (cream only) age 26 and older
• Tazorac cream age 26 and over
• Growth hormones/Growth Hormone Releasing Hormones
• Oral Contraceptives (except Emergency Contraceptives) for females only
• 91 day Pre-packaged Oral Contraceptives up to a 91-day supply for females only
• PDST (Preferred Drug Step Therapy) - For a list of drugs that require PDST, contact CVS Caremark
customer service
• Transdermal and Intravaginal Contraceptives for females only
• Anti-Obesity/Weight Loss Drugs (Legend Anti-Obesity Preparations)
• Erythroid Stimulants
• Myeloid Stimulants
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• Platelet Proliferation Stimulants
• MS Agents
• Tysabri
• Interferons
• Xolair
• Provigil
NOTE: Drugs for cancer therapy and the reasonable cost of administering them are usually covered. The
Prescription Drug Plan may implement prior authorization rules to determine if the cancer therapy is eligible
for coverage under the Plan based on the plan rules. Certain off-label uses of cancer drugs may not be
eligible for coverage under the Plan if there is insufficient published evidence to determine the toxicity, safety
and/or efficacy of the cancer therapy for the specific cancer it is prescribed to treat.
EXCLUSIONS
The following are excluded from coverage unless specifically listed as a benefit under “Covered Drugs”:
• Non-Federal Legend Drugs
• Contraceptive medications, jellies, creams, foams, devices, implants or injections, whether or not
dispensed by prescription, which are purchased or prescribed for the sole purpose of preventing
conception, including diaphragms
• Emergency contraceptives
• Retin-A (except cream) age 26 and older
• Non-sedating antihistamines/non-sedating antihistamine combo products (SPECs: Z2O, Z2Q)
• Zostavax through age 59
• Drug to treat impotency
• Mifeprex
• Therapeutic devices or appliances
• Drugs whose sole purpose is to promote or stimulate hair growth or for cosmetic purposes only (e.g.,
Rogain)
• Allergy Sera
• Biologicals, Immunization agents or Vaccines
• Blood or blood plasma products
• Drugs labeled "Caution-limited by Federal law to investigational use", or Experimental drugs, even
though a charge is made to the Covered Individual
• Medication for which the cost is recoverable under any Workers' Compensation or Occupational Disease
Law or any State or Governmental Agency, or medication furnished by any other Drug or Medical
Service for which no charge is made to the Covered Individual
• Medication which is to be taken by or administered to a Covered Individual, in whole or in part, while he
or she is a patient in a licensed Hospital, rest home, sanitarium, extended care facility, skilled nursing
facility, Convalescent Facility, nursing home or similar institution which operates on its premises or allows
to be operated on its premises, a facility for dispensing pharmaceuticals
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• Any prescription refilled in excess of the number of refills specified by the Physician, or any refill
dispensed after one year from the Physician's original order
• Charges for the administration or injection of any drug
• Non-prescription smoking cessation procedures and smoking deterrents
DISPENSING LIMITS
• The amount of drug which is to be dispensed per prescription or refill (regardless of dosage form) will be
in quantities prescribed up to a 34-day supply.
• Thalomid limited to a 28-day supply.
FILING CLAIMS
In certain situations, you or your Dependent will have to file your own claims in order to obtain benefits for
Prescription Drugs. This is primarily true when you or your Dependent did not receive an ID card, the
pharmacy was unable to transmit a claim or you or your Dependent purchases a drug at a pharmacy that
does not participate in the CVS Caremark program. To do so, follow these instructions:
1) Complete a Prescription Drug claim form. These forms are available from your Employer or the
Prescription Drug Claim Administrator’s office.
2) Attach copies of all pharmacy receipts to be considered for benefits. These receipts must be itemized.
3) Mail the completed claim form with attachments to:
CVS Caremark
P.O. Box 94467
Palatine, IL 60094-4467
In any case, claims must be filed no later than one year after the date a service or supply is received.
Claims not filed within one year from the date a service or supply is received will not be eligible for
payment.
If you or your Dependent purchases a drug at a pharmacy that does not participate in the CVS Caremark
program, and your claim is approved, you will be reimbursed the amount that would have been paid to the
pharmacy minus the cash Copayment you would have paid at a participating pharmacy.
If your claim is wholly or partially denied, within 30 days after its receipt of your claim, the Prescription
Drug Claims Administrator will notify you of its decision in a written or electronic communication pursuant
to Department of Labor Regulations Sections 2520.104b-1(c)(1), (iii) and (iv), which will contain:
1) The specific reason(s) for the denial;
2) References to the pertinent Plan provisions on which the decision is based;
3) A description of any additional material or information needed to support the claim;
4) A description of the Plan’s claim review procedure and the time limits applicable to such procedure;
5) Reference to any internal rule, guideline or protocol relied upon in making the decision; and
6) If the claim denial is based on a Medical Necessity or Experimental treatment or similar exclusion or
limit, either an explanation of the scientific or clinical judgment for the adverse determination, applying
the terms of the Plan to your medical circumstances, or a statement that such explanation will be
provided free of charge upon request.
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Effective July 1, 2011 (or such later date required by applicable law), the notification will also include:
7) Information sufficient to identify the claim involved, including the date of service, the health care
provider, the Claim amount (if applicable), the diagnosis code and its corresponding meaning, and the
treatment code and its corresponding meaning;
8) The denial code, if any, and its corresponding meaning;
9) A description of the standard, if any, that was used in denying the claim; and
10) A description of available external review processes, including instructions on how to initiate an
appeal.
A 15-day extension of the time period for deciding claims may be allowed, provided that the Claim
Administrator determines that the extension is necessary due to matters beyond its control. If such an
extension is necessary, the Claim Administrator must notify you before the end of the 30-day period of the
reason(s) requiring the extension and the date it expects to provide a decision on your claim. If such an
extension is necessary due to your failure to submit the information necessary to decide the claim, the
notice of extension must also specifically describe the required information. You then have 45 days to
provide the information needed to process your claim. If you do not provide the required information
within the 45-day period, your claim may be denied. If an extension is necessary due to your failure to
submit necessary information, the Plan’s time frame for making a benefit determination is stopped from
the date the Claim Administrator sends you an extension notification until the date you respond to the
request for additional information, or the expiration of the 45-day period within which you were to provide
the additional information, if earlier. The Claim Administrator will notify you of its determination with
respect to your claim within 15 days after the earlier of these dates.
CLAIMS APPEAL PROCEDURES
If your claim has been denied in whole or in part you may appeal the decision. Your written request for
review or reconsideration must be made in writing to the address indicated in the claim denial letter within
180 days after you receive notice of a claim denial. While the Claim Administrator will honor telephone
requests for information, such inquiries will not constitute a request for appeal. You may designate a
representative to act for you in the appeal procedure. Your designation of a representative must be in
writing as it is necessary to protect against disclosure of information about you except to your Authorized
Representative.
As part of your appeal, you or your Authorized Representative have the right to:
1) Submit written comments, documents, records and other information relating to your claim for
benefits that you wish to have considered;
2) Request, free of charge, reasonable access to, and copies of, all documents, records and other
information relevant to your claim for benefits;
3) A review that takes into account all comments, documents, records and other information submitted
by you related to the claim, regardless of whether the information was submitted or considered in the
initial benefit determination;
4) A review that does not defer to the initial claim determination and that is conducted by someone other
than the individual who made the adverse determination, and who is not such person’s subordinate;
and
5) In cases where the claim denial was based in whole or in part on medical judgment, require the
individual reviewing the appeal to consult with a Health Care Professional who has appropriate
training and experience in the field of medicine involved in the medical judgment, who was not
consulted in connection with the initial claim determination, and who is not such person’s subordinate.
Ordinarily, a decision on an appeal will be reached within 30 days after receipt of your appeal.
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The Claim Administrator will notify you if your appeal is denied. Such notification will include:
1) The specific reason(s) for the denial;
2) References to the pertinent Plan provisions on which the denial is based;
3) Reference to any internal rule, guideline or protocol relied upon in making the decision;
4) If the claim denial is based on a Medical Necessity or Experimental treatment or similar exclusion or
limit, either an explanation of the scientific or clinical judgment for the adverse determination, applying
the terms of the Plan to your medical circumstances, or a statement that such explanation will be
provided free of charge upon request;
5) A statement that you are entitled to receive, upon request and free of charge, reasonable access to,
and copies of, all documents, records and other information relevant to your claim; and
6) Information concerning your right to bring a civil action for benefits under section 502(a) of ERISA.
Effective July 1, 2011 (or such later date required by applicable law), if your claim appeal is going to be
denied by the Claim Administrator, the Claim Administrator must provide you, free of charge, any new or
additional evidence considered, relied upon, or generated by the Claim Administrator (or at the direction
of the Claim Administrator) in connection with the claim appeal. Any such evidence will be provided as
soon as possible and sufficiently in advance of the date on which the Claim Administrator’s notice of its
decision on your claim appeal must be provided so that you have a reasonable opportunity to respond
prior to that date. In addition, effective July 1, 2011 (or such later date required by applicable law), if the
claim Administrator’s decision on your claim appeal is based on a new or additional rationale from the
initial claim decision, you will be provided, free of charge, with the rationale as soon as possible and
sufficiently in advance of the date on which the Claim Administrator’s notice of its decision on your claim
appeal must be provided so that you have a reasonable opportunity to respond prior to that date.
EXTERNAL REVIEW
Effective January 1, 2011 (or such later date required by applicable law), there will be an external review
process for claim review denials (except a denial, reduction, termination, or a failure to provide payment
for a benefit based on a determination that you are not eligible under the terms of the Plan). Information
regarding the external review process is available by contacting CVS Caremark Customer Service at 800-
875-0867.
Your Prescription Drug Copayments are not eligible expenses in this Plan and may not be applied to any
Deductible or Out-of-Pocket Maximum expense limits.
Controlled drugs cannot be purchased through the mail order program.
NOTE: This Plan does not coordinate benefits on Prescription Drug charges that are provided through
Pharmacy Benefit Managers.
For questions related to your Prescription Drug plan, contact CVS Caremark at 800-875-0867.
NON-SURGICAL WEIGHT LOSS PROGRAMS/SMOKING CESSATION
The Plan will cover services for non-surgical weight loss treatment /smoking cessation therapy. These
benefits are not subject to Deductible and Out-of-Pocket Maximums. Benefits are payable at 100% up to a
$500 annual maximum and include:
• Outpatient counseling or therapy;
• Office visits rendered by a licensed Physician for the treatment of weight loss / smoking cessation;
• Lab services performed during a course of treatment; and
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• Services for weight loss render by a Trinity Health Ministry Organization or national recognized
programs such as Jenny Craig, Weight Watchers and LA Weight Loss.
NOT COVERED:
• Services administered exclusively in a Web-based forum;
• Pharmacotherapy and/or injection expenses associated with smoking cessation or weight loss,
unless otherwise covered for an unrelated medical condition (pharmacotherapy expenses associated
with smoking cessation or weight loss are covered under the prescription drug program under the
Plan);
• Charges for food and/or nutritional supplements, unless included in the initial program fee;
• Charges for over-the-counter diet aids and/or smoking cessation aids;
• Health clubs and exercise equipment;
• Services and/or programs not approved in the United States; and
• Charges in connection with acupuncture, hypnotism, and/or biofeedback training.
SPINAL DISORDER TREATMENT BENEFIT
Covered Expenses include charges incurred for:
• Manipulative (adjustive) treatment; or
• Other physical treatment;
of any condition caused by or related to biomechanical or nerve conduction disorders of the spine.
The Chiropractic maximum does not apply to expenses incurred:
• While the person is a full-time Inpatient in a Hospital;
• For treatment of scoliosis;
• For fracture care; or
• For Surgery (including pre and post-surgical care given or ordered by the operating Physician).
OTHER MEDICAL EXPENSES
Covered Expenses include:
• Charges made by a Physician
• Charges for the following:
o Diagnostic lab work and X-rays
o X-ray, radium, and radioactive isotope therapy
o Anesthetics and oxygen
• Rental of durable medical and surgical equipment. In lieu of rental, the following may be covered:
o The initial purchase of such equipment if Aetna is shown that: long-term care is planned; and that
such equipment: either cannot be rented; or is likely to cost less to purchase than to rent
o Repair of purchased equipment
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o Replacement of purchased equipment if Aetna is shown that it is needed due to a change in the
Covered Individual’s physical condition; or it is likely to cost less to purchase a replacement than to
repair existing equipment or to rent like equipment
• Professional ambulance service to transport a person from the place where he or she is Injured or
stricken by Illness to the first Hospital where treatment is given
• Artificial limbs and eyes
Covered Expenses do not included are such things as:
• Eyeglasses;
• Vision aids;
• Hearing aids;
• Communication aids
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COMPLEX IMAGING SERVICES
Covered Expenses include charges for Complex Imaging Services received by a Covered Individual on an
Outpatient basis when performed in:
1) A Physician's office
2) A Hospital Outpatient department or emergency room
3) A Hospital confinement
4) A licensed radiological facility
Complex Imaging Services include:
1) C.A.T. Scans;
2) Magnetic Resonance Imaging (MRIs);
3) Positron Emission Tomography (PET Scans); and
4) any other Outpatient diagnostic imaging service costing over $500.
Deductibles, Copayments and other cost sharing features; maximum benefit amounts; and exclusions apply
NATIONAL MEDICAL EXCELLENCE PROGRAM ® (NME)
The NME Program coordinates all solid organ and bone marrow transplants and other specialized care that
cannot be provided within an NME Patient's local geographic area. When care is directed to a facility
("Medical Facility") more than 100 miles from the person's home, this Plan will pay a benefit for Travel and
Lodging Expenses, but only to the extent described in the Benefits Summary. See the Benefits Summary for
the Plan Lodging and Travel Expenses Maximums.
TRAVEL EXPENSES
These are expenses incurred by an NME Patient for transportation between his or her home and the Medical
Facility to receive services in connection with a procedure or treatment.
Also included are expenses incurred by a Companion for transportation when traveling to and from an NME
Patient’s home and the Medical Facility to receive such services.
LODGING EXPENSES
These are expenses incurred by an NME Patient for lodging away from home while traveling between his or
her home and the Medical Facility to receive services in connection with a procedure or treatment.
The benefit payable for these expenses will not exceed the Lodging Expenses Maximum per person per
night.
Also included are expenses incurred by a Companion for lodging away from home:
• While traveling with an NME Patient between the NME Patient’s home and the Medical Facility to receive
services in connection with any listed procedure or treatment; or
• When the Companion’s presence is required to enable an NME Patient to receive such services from the
Medical Facility on an Inpatient or Outpatient basis.
The benefit payable for these expenses will not exceed the Lodging Expenses Maximum per person per
night.
For the purpose of determining NME Travel Expenses or Lodging Expenses, a Hospital or other temporary
residence from which an NME Patient travels in order to begin a period of treatment at the Medical Facility, or
65

to which he or she travels after discharge at the end of a period of treatment, will be considered to be the
NME Patient’s home.
TRAVEL AND LODGING BENEFIT MAXIMUM
For all Travel Expenses and Lodging Expenses incurred in connection with any one procedure or treatment
type:
• The total benefit payable will not exceed the Travel and Lodging Maximum per episode of care
• Benefits will be payable only for such expenses incurred during a period which begins on the day a
Covered Individual becomes an NME Patient and ends on the earlier of:
o One year after the day the procedure is performed; or
o The date the NME Patient ceases to receive any services from the facility in connection with the
procedure.
Benefits paid for Travel Expenses and Lodging Expenses do not count against any Covered Individual’s
Maximum Benefit.
LIMITATIONS
Travel Expenses and Lodging Expenses do not include, and no benefits are payable for, any charges which
are included as Covered Expenses under any other part of this Plan.
Travel Expenses do not include expenses incurred by more than one Companion who is traveling with the
NME Patient.
Lodging Expenses do not include expenses incurred by more than one Companion per night.
WEIGHT MANAGEMENT
The Plan provides for services as described below. For plan coverage specifics please refer to the Benefits
Summary.
COVERED EXPENSES
All expenses related to the treatment of Morbid Obesity that are otherwise payable under the Plan will be
considered allowable expenses (e.g. Surgery, hospitalization, anesthesia, office visits for a Physician, lab
testing, psychotherapy, etc. Services will be payable as described in each respective section). For purposes
of determining these benefits, the Plan will base the determination of Morbid Obesity on the Covered
Individual’s Body Mass Index (BMI) or overweight status. A BMI greater than 40, or more than 80 pounds
overweight for a female or more than 100 pounds overweight for a male will be considered indicative of
Morbid Obesity. A BMI greater than 35 but less than 40 will also be considered indicative of Morbid Obesity
where the patient has one or more of the following co-morbid conditions; severe sleep apnea, Pickwickian
syndrome, Congestive heart failure, cardiomyopathy, Insulin dependent diabetes or severe musculoskeletal
dysfunction, that are either life threatening or which significantly impair a major life function (e.g., mobility,
ability to work, ability to self care). Documentation of the medical treatment of the co-morbid conditions that
demonstrates the Covered Individual meets these criteria must be provided.
Additionally, the Plan will review Covered Individual’s history for optimal candidacy for any proposed surgical
treatment according to current, generally accepted medical practices. For example, this review will consider
whether the Covered Individual has been unable to lose weight through non-surgical, conventional measures
and whether the Covered Individual’s ability to manage the surgical intervention and required post-operative
care has been assessed through a psychological evaluation.
The Plan will review if the Covered Individual has undergone a Physician supervised nutrition, exercise and
weight loss program for a minimum of six months, within the 12 months immediately preceding the proposed
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Surgery, during which the Covered Individual was found unable to meet the Physician’s weight loss goals.
Unsuccessful weight loss attempts and lifestyle changes will require documentation by medical office
progress notes and a letter from the attending Physician as to why non-invasive weight loss attempts are no
longer a standard of care for the patient.
If confirmation is obtained from the attending surgeon that the program the Covered Individual will be under
includes a complete support team with required follow ups, etc. a psychological evaluation is not required.
Other limitations include:
1) Appendectomies and cholecystectomies in conjunction with surgical treatment of Morbid Obesity will be
considered incidental and not covered unless the Covered Individual has an existing condition that
requires the additional surgical treatment.
2) Subsequent panniculectomy (Surgery to remove loose skin) resulting from weight loss will be covered
only if it is Medically Necessary as a result a documented history of treatment by a Physician for related
Illnesses for a minimum of six months where the treated condition is no longer controlled through any
other means.
3) Bariatric Surgical intervention beyond one course of treatment per lifetime.
NOTE: Please refer to the sections titled CONSULTATIONS, LABORATORY/PATHOLOGICAL TESTING,
X-RAY AND X-RAY INTERPRETATION and OFFICE VISITS for information regarding coverage for
consultations, laboratory/pathological tests, x-rays and office visits related to covered weight management
procedures.
NOT COVERED:
Prescription drugs without prior authorization
LIMITATIONS
PREVENTIVE MAMMOGRAM
Even though not incurred in connection with an Illness or Injury, Covered Expenses include charges incurred
by a female age 35 or over for a routine mammogram as follows:
• One baseline mammogram, for a person age 35 but less than 40.
• One mammogram each calendar year, for a person age 40 or over.
PREVENTIVE SCREENING FOR CANCER
Even though not incurred in connection with an Illness or Injury, Covered Expenses include charges incurred
for:
• One digital rectal exam and a prostate specific antigen (PSA) test each calendar year, for a male age 40
or over; and
• One colorectal cancer screening every 10 years, for persons age 50 or over, for routine screening for
cancer.
• Also covers one sigmoidoscopy each calendar year, for a person age 40 or over.
MOUTH, JAWS AND TEETH
Covered Expenses include the services rendered and supplies needed for treatment of or related to
conditions of the following:
• Teeth, mouth, jaws, jaw joints; or
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• Supporting tissues (this includes bones, muscles, and nerves).
For these expenses, "Physician" includes a Dentist.
Surgery needed to:
• Treat a fracture, dislocation, or wound.
• Cut out:
o Teeth partly or completely impacted in the bone of the jaw;
o Teeth that will not erupt through the gum;
o Other teeth that cannot be removed without cutting into bone;
o The roots of a tooth without removing the entire tooth;
o Cysts, tumors, or other diseased tissues.
• Cut into gums and tissues of the mouth. This is only covered when not done in connection with the
removal, replacement or repair of teeth.
• Alter the jaw, jaw joints or bite relationships by a cutting procedure when appliance therapy alone cannot
result in functional improvement
Non-surgical treatment of infections or diseases. This does not include those of or related to the teeth.
Dental work, Surgery and Orthodontic Treatment needed to remove, repair, replace, restore or reposition of
the following due to injury:
• Natural teeth damaged, lost, or removed; or
• Other body tissues of the mouth fractured or cut.
Any such teeth must have been:
• Free from decay; or
• In good repair; and
• Firmly attached to the jaw bone at the time of the Injury.
The treatment must be done in the calendar year of the accident or the next one.
If:
• Crowns (caps); or
• Dentures (false teeth); or
• Bridgework; or
• In-mouth appliances;
Are installed due to such Injury, Covered Expenses include only charges for:
• The first denture or fixed bridgework to replace lost teeth;
• The first crown needed to repair each damaged tooth; and
• An in-mouth appliance used in the first course of Orthodontic Treatment after the Injury.
Except as provided for Injury, Covered Expenses do not include charges:
• For in-mouth appliances, crowns, bridgework, dentures, tooth restorations, or any related fitting or
adjustment services; whether or not the purpose of such services or supplies is to relieve pain;
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• For root canal therapy;
• For routine tooth removal (not needing cutting of bone).
In addition, Covered Expenses do not include charges:
• To remove, repair, replace, restore or reposition teeth lost or damaged in the course of biting or chewing;
• To repair, replace, or restore filling, crowns, dentures or bridgework;
• For non-surgical periodontal treatment;
• For dental cleaning, in-mouth scaling, planning or scraping;
• For myofunctional therapy; this is:
o Muscle training therapy; or
o Training to correct or control harmful habits.
EMERGENCY ROOM TREATMENT
EMERGENCY CARE
If treatment:
• Is received in the emergency room of a Hospital while a person is not a full-time Inpatient; and
• The treatment is Emergency Care;
Covered Expenses for charges made by the Hospital for such treatment will be paid at the Payment
Percentage.
NON-EMERGENCY CARE
Benefits will be payable at the payment percentage if treatment:
• Is received in the emergency room of a Hospital while a person is not a full-time Inpatient; and
• The treatment is not Emergency Care;
TREATMENT BY AN URGENT CARE PROVIDER
You should not seek medical care or treatment from an Urgent Care Provider if your Illness, Injury, or
condition is an emergency condition. Please go directly to the emergency room of a Hospital or call 911 (or
the local equivalent) for ambulance and medical assistance.
URGENT CARE
This Plan pays for the charges made by an Urgent Care Provider to evaluate and treat an Urgent Condition.
When travel to an Urgent Care Provider for treatment of an Urgent Condition is not feasible, such treatment
may be paid at the Preferred level of benefits. If a claim for treatment of an Urgent Condition is paid at the
Non-Preferred level and you believe that it should have been paid at the Preferred level, please contact
Members Services at the toll-free number on your I.D. card.
NON-URGENT CARE
For benefit coverage reference Benefits Summary for Covered Expenses for charges made by an Urgent
Care Provider to treat a non-Urgent Condition.
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Non-Urgent Care includes, but is not limited to, the following:
• Routine or preventive care (this includes immunizations);
• Follow-up care;
• Physical therapy;
• Elective surgical procedures; and
• Any lab and radiologic exams which are not related to the treatment of the Urgent Condition.
TREATMENT OF ALCOHOLISM, DRUG ABUSE, OR MENTAL DISORDERS
Certain expenses for the treatment shown below are Covered Expenses.
INPATIENT TREATMENT
The following coverage applies if a Covered Individual is a full-time Inpatient in either a Hospital or a
Residential Treatment Facility:
HOSPITAL
Covered Expenses include:
• Treatment of the medical complications of alcoholism or drug abuse (this means such as cirrhosis of the
liver, delirium tremens, or hepatitis)
• Effective Treatment of Alcoholism or Drug Abuse
• Effective Treatment of Mental Disorders
RESIDENTIAL TREATMENT FACILITY
Covered Expenses for the Effective Treatment of Alcoholism or Drug Abuse or the Treatment of Mental
Disorders include:
• Board and room (however, any charge for daily room and board in a private room over the Private Room
Limit is not covered)
• Other necessary services and supplies
OUTPATIENT TREATMENT
The following coverage applies if a Covered Individual is not a full-time Inpatient either a Hospital or a
Residential Treatment Facility:
Expenses for the Effective Treatment of Alcoholism or Drug Abuse or the Treatment of Mental Disorders are
covered.
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GENERAL EXCLUSIONS
GENERAL EXCLUSIONS APPLICABLE TO HEALTH EXPENSE COVERAGE
Coverage is not provided for the following charges:
• Those for services and supplies not Medically Necessary, as determined by Aetna in accordance with the
terms of the Plan, for the diagnosis, care, or treatment of the Illness or Injury involved. This applies even
if they are prescribed, recommended, or approved by the Covered Individual's attending Physician.
• Those for care, treatment, services, or supplies that are not prescribed, recommended, or approved by
the Covered Individual's attending Physician.
• Those for or in connection with services or supplies that are, as determined by Aetna, to be Experimental
or Investigational. A drug, a device, a procedure, or treatment will be determined to be Experimental or
Investigational if:
o There are insufficient outcomes data available from controlled clinical trials published in the peer
reviewed literature to substantiate its safety and effectiveness for the Illness or Injury involved; or
o If required by the FDA, approval has not been granted for marketing; or
o A recognized national medical or dental society or regulatory agency has determined, in writing, that
it is Experimental, Investigational, or for research purposes; or
o The written protocol or protocols used by the treating facility, or the protocol or protocols of any other
facility studying substantially the same drug, device, procedure, or treatment, or the written informed
consent used by the treating facility or by another facility studying the same drug, device, procedure,
or treatment states that it is Experimental, Investigational, or for research purposes.
However, this exclusion will not apply with respect to services or supplies (other than drugs) received in
connection with an Illness; if Aetna determines that:
• The Illness can be expected to cause death within one year, in the absence of Effective Treatment; and
• The care or treatment is effective for that Illness or shows promise of being effective for that Illness as
demonstrated by scientific data. In making this determination Aetna will take into account the results of a
review by a panel of independent medical professionals. They will be selected by Aetna. This panel will
include professionals who treat the type of disease involved.
Also, this exclusion will not apply with respect to drugs that:
• Have been granted treatment investigational new drug (IND) or Group c/treatment IND status; or
• Are being studied at the Phase III level in a national clinical trial sponsored by the National Cancer
Institute; if Aetna determines that available scientific evidence demonstrates that the drug is effective or
shows promise of being effective for the Illness
• Those for or related to services, treatment, education testing, or training related to learning disabilities or
developmental delays
• Those for care furnished mainly to provide a surrounding free from exposure that can worsen the
Covered Individual’s Illness or Injury
• Those for or related to the following types of treatment: primal therapy; rolfing; psychodramamegavitamin
therapy; bioenergetic therapy; vision perception training; or carbon dioxide therapy
• Those for treatment of covered health care providers who specialize in the mental health care field and
who receive treatment as a part of their training in that field
• Those for services of a resident Physician or intern rendered in that capacity
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• Those that are made only because there is health coverage
• Those that a Covered Individual is not legally obliged to pay
• Those, as determined by Aetna, to be for Custodial Care
• Those for services and supplies:
o Furnished, paid for, or for which benefits are provided or required by reason of the past or present
service of any person in the armed forces of a government
o Furnished, paid for, or for which benefits are provided or required under any law of a government
(this exclusion will not apply to "no fault" auto insurance if it: is required by law; is provided on other
than a group basis; and is included in the definition of Other Plan in the section entitled Effect of
Benefits Under Other Plans Not Including Medicare. In addition, this exclusion will not apply to: a
plan established by government for its own associates or their dependents; or Medicaid.)
• Those for or related to any eye Surgery mainly to correct refractive errors
• Those for education or special education or job training whether or not given in a facility that also
provides medical or psychiatric treatment
• Those for therapy, supplies, or counseling for sexual dysfunctions or inadequacies that do not have a
physiological or organic basis
• Those for any drugs or supplies used for the treatment of erectile dysfunction, impotence, or sexual
dysfunction or inadequacy, including but not limited to:
o Sildenafil citrate;
o Phentolamine;
o Apomorphine;
o Alprostadil; or
o Any other drug that is in a similar or identical class, has a similar or identical mode of action or
exhibits similar or identical outcomes.
This exclusion applies whether or not the drug is delivered in oral, injectable, or topical (including but not
limited to gels, creams, ointments, and patches) forms, except to the extent coverage for such drugs or
supplies is specifically provided in your Benefits Summary.
• Those for performance, athletic performance or lifestyle enhancement drugs or supplies, except to the
extent coverage for such drugs or supplies is specifically provided in your Benefits Summary
• Those for or related to sex change Surgery or to any treatment of gender identity disorders
• Those for or related to artificial insemination, in-vitro fertilization, fertility drugs (refer to the Prescription
Drug section on page 57), or embryo transfer procedures
• GIFT (Gacmete Intrafallopian Transfer). ZIFT
• Charges for contraceptive pills, devices, implants and injections, unless Medically Necessary
• Those for routine physical exams, routine vision exams, routine dental exams, routine hearing exams,
immunizations, or other preventive services and supplies, except to the extent coverage for such exams,
immunizations, services, or supplies are specifically provided in your Benefits Summary
• Those for or in connection with marriage, family, child, career, social adjustment, pastoral, or financial
counseling
• Those for acupuncture therapy. Not excluded is acupuncture when it is performed by a Physician as a
form of anesthesia in connection with Surgery that is covered under this Plan
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• Those for or in connection with speech therapy. This exclusion does not apply to charges for speech
therapy that is expected to restore speech to a Covered Individual who has lost existing speech function
(the ability to express thoughts, speak words, and form sentences) as the result of an Illness or Injury
• Those for services and supplies that, in the opinion of the Claims Administrator or its Authorized
Representative, are associated with Injuries, Illness, or conditions suffered due to the acts or omissions
of a third party
• Claims filed later than one year from the date the charge was incurred
• Charges incurred by a surrogate mother
• Termination of pregnancy (abortion)
• Charges incurred as a result of committing an assault, felony or any illegal or criminal activity.
• Services rendered for treatment of any Injury or Illness for which benefits are available under Workers’
Compensation or Employer Liability Law, and such coverage must be purchased by law, whether or not
such coverage is in force, and whether or not such benefits are received by the Covered Individual.
Occupational Illness or Injury includes those as a result of any work for wage or profit.
• Those for plastic surgery, reconstructive surgery, cosmetic surgery, or other services and supplies which
improve, alter, or enhance appearance, whether or not for psychological or emotional reasons; except to
the extent needed to:
o Improve the function of a part of the body that:
� Is not a tooth or structure that supports the teeth; and
� Is malformed:
• As a result of a severe birth defect; including cleft lip, webbed fingers, or toes; or
• As a direct result of:
o Illness; or
o Surgery performed to treat an Illness or Injury.
o Repair an Injury. Surgery must be performed:
� In the calendar year of the accident which causes the Injury; or
� In the next calendar year.
o Those to the extent they are not Reasonable Charges, as determined by Aetna
o Those for a voluntary sterilization procedure, reversal of a sterilization procedure, or abortion
o Services, care, treatment, and referrals rendered by the Covered Individual’s family, including - but
not limited to - spouse, mother, father, grandmother, grandfather, in-laws, son, daughter, stepchildren
or any person who resides with the Covered Individual
o Those for a service or supply furnished by a Preferred Care Provider in excess of such Provider's
Negotiated Charge for that service or supply. This exclusion will not apply to any service or supply
for which a benefit is provided under Medicare before the benefits of the Plan are paid.
Any exclusion above will not apply to the extent that coverage of the charges is required under any law that
applies to the coverage.
These excluded charges will not be used when figuring benefits.
The law of the jurisdiction where a Covered Individual lives when a claim occurs may prohibit some benefits.
If so, they will not be paid.
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This is a summary of the most important provisions of the Plan. Details of the Plan provisions can be
found in the official Plan document. The Plan document is always used in cases requiring a legal
interpretation of the Plan. If there is any difference between a Plan document and this summary, your
rights will be based on the provisions of the Plan document (and any legal rules that require changes not
yet written in to the Plan document).
029142, 000036, 103722041.2
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